Provider Demographics
NPI:1962021162
Name:JACOBI, MAURA CLEMENT (MD)
Entity Type:Individual
Prefix:
First Name:MAURA
Middle Name:CLEMENT
Last Name:JACOBI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MAURA
Other - Middle Name:ELIZABETH
Other - Last Name:CLEMENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2025 SLOAN PL STE 35
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-2092
Mailing Address - Country:US
Mailing Address - Phone:651-772-1572
Mailing Address - Fax:651-772-1889
Practice Address - Street 1:234 WENTWORTH AVE E
Practice Address - Street 2:
Practice Address - City:WEST SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-3525
Practice Address - Country:US
Practice Address - Phone:651-455-2940
Practice Address - Fax:651-455-3354
Is Sole Proprietor?:No
Enumeration Date:2020-04-09
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN71440207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program