Healthcare Provider Details

I. General information

NPI: 1366418212
Provider Name (Legal Business Name): JODI LYNN ANDERSON ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 05/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 17TH AVE E
ALEXANDRIA MN
56308-5273
US

IV. Provider business mailing address

111 17TH AVE E
ALEXANDRIA MN
56308-5273
US

V. Phone/Fax

Practice location:
  • Phone: 320-762-1144
  • Fax: 320-762-1935
Mailing address:
  • Phone: 320-762-1144
  • Fax: 320-762-1935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00143900
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1444
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: