Provider Demographics
NPI:1871962209
Name:JACOBSON, HEIDI
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:
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:E6487 1370TH AVE.
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:WI
Mailing Address - Zip Code:54763
Mailing Address - Country:US
Mailing Address - Phone:715-790-3457
Mailing Address - Fax:
Practice Address - Street 1:E6487 1370TH AVE
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:WI
Practice Address - Zip Code:54763-9439
Practice Address - Country:US
Practice Address - Phone:715-790-3457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI122555-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse