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General NPI Number Information
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NPI Number | 1053088245
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Entity Type | Individual
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Provider Name | DOROTHY LEE JENICKE STUDENT
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Gender | Female
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Dates
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Enumeration Date | 08/25/2021
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Last Update Date | 11/13/2024
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Provider Practice Location Address
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Address Line | 8053 E BLOOMINGTON FWY
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City | BLOOMINGTON
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State | MN
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Zip | 55420-4577
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Country | US
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Telephone | 612-333-2155
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Fax |
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Provider Business Mailing Address
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Address Line | 946 HAWTHORNE AVE E
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City | SAINT PAUL
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State | MN
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Zip | 55106-2012
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Country | US
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Telephone | 989-289-5997
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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