Provider Demographics
NPI:1669238648
Name:CORDOVA-JACOBSON, DANA LEANN
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:LEANN
Last Name:CORDOVA-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 1:1906 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4700
Mailing Address - Country:US
Mailing Address - Phone:719-680-2093
Mailing Address - Fax:
Practice Address - Street 1:509 3RD AVE NE
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-3213
Practice Address - Country:US
Practice Address - Phone:719-680-2093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator