Basic Information
| Provider Information | |||||||||
| NPI: | 1760153597 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | JODI | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9220 GLACIER RD | ||||||||
| Address2: | |||||||||
| City: | MINNETRISTA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553751347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9522921127 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1805 HENNEPIN AVE N | ||||||||
| Address2: | |||||||||
| City: | GLENCOE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553361416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3208643121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2021 | ||||||||
| LastUpdateDate: | 09/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 8551 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.