Provider Demographics
NPI:1649064403
Name:JACOBS, JEREMY JAMES
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:JAMES
Last Name:JACOBS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5860 BAKER RD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-5903
Mailing Address - Country:US
Mailing Address - Phone:952-767-4200
Mailing Address - Fax:952-767-4211
Practice Address - Street 1:2508 WASHINGTON AVE SE
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-8847
Practice Address - Country:US
Practice Address - Phone:952-767-4200
Practice Address - Fax:952-767-4211
Is Sole Proprietor?:No
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician