Provider Demographics
NPI:1396861217
Name:DAHL, JODELL E (RN, MS, CNP)
Entity Type:Individual
Prefix:MS
First Name:JODELL
Middle Name:E
Last Name:DAHL
Suffix:
Gender:F
Credentials:RN, MS, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 OAK GROVE PLACE
Mailing Address - Street 2:
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-2759
Mailing Address - Country:US
Mailing Address - Phone:612-626-2804
Mailing Address - Fax:612-626-2815
Practice Address - Street 1:2450 RIVERSIDE AVE SE
Practice Address - Street 2:EAST BUILDING JOURNEY CLINIC 9E
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-0341
Practice Address - Country:US
Practice Address - Phone:612-365-8100
Practice Address - Fax:612-626-2815
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0866590363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNS97211Medicare UPIN