1952396111 NPI number — JODINE L JANZEN OD

Table of content: JODINE L JANZEN OD (NPI 1952396111)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952396111 NPI number — JODINE L JANZEN OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JANZEN
Provider First Name:
JODINE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1952396111
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 1ST AVE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMBRIDGE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55008-1209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-689-1494
Provider Business Mailing Address Fax Number:
763-691-8395

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 1ST AVE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMBRIDGE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55008-1209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-689-1494
Provider Business Practice Location Address Fax Number:
763-691-8395
Provider Enumeration Date:
09/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152WC0802X , with the licence number:  2586 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 410047970 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1014827 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 64G67JA . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 321025100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2201810 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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