Provider Demographics
NPI:1376687657
Name:FIDLER, JODI LYNN (DC)
Entity Type:Individual
Prefix:DR
First Name:JODI
Middle Name:LYNN
Last Name:FIDLER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4415 EXCELSIOR BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4813
Mailing Address - Country:US
Mailing Address - Phone:952-925-4085
Mailing Address - Fax:952-925-1394
Practice Address - Street 1:4415 EXCELSIOR BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-4813
Practice Address - Country:US
Practice Address - Phone:952-925-4085
Practice Address - Fax:952-925-1394
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3273111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor