Provider Demographics
NPI:1205319225
Name:JACOBSON, SHELLEY JEAN
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:JEAN
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6960 COUNTY ROAD 17
Mailing Address - Street 2:
Mailing Address - City:BOWBELLS
Mailing Address - State:ND
Mailing Address - Zip Code:58721-9418
Mailing Address - Country:US
Mailing Address - Phone:701-377-2122
Mailing Address - Fax:701-377-2122
Practice Address - Street 1:6960 COUNTY ROAD 17
Practice Address - Street 2:
Practice Address - City:BOWBELLS
Practice Address - State:ND
Practice Address - Zip Code:58721-9418
Practice Address - Country:US
Practice Address - Phone:701-377-2122
Practice Address - Fax:701-377-2122
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-14
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR26493163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Single Specialty