Provider Demographics
NPI:1215224381
Name:MIXDORF, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MIXDORF
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 1:214 VIKING PLAZA RD
Mailing Address - Street 2:T-2526
Mailing Address - City:CEDAR FALLS
Mailing Address - State:IA
Mailing Address - Zip Code:50613-6936
Mailing Address - Country:US
Mailing Address - Phone:319-553-1121
Mailing Address - Fax:319-553-1131
Practice Address - Street 1:214 VIKING PLAZA RD
Practice Address - Street 2:T-2526
Practice Address - City:CEDAR FALLS
Practice Address - State:IA
Practice Address - Zip Code:50613-6936
Practice Address - Country:US
Practice Address - Phone:319-553-1121
Practice Address - Fax:319-553-1131
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-08
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21028183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist