Provider Demographics
NPI:1407000490
Name:HAGER, JODI LYNN (ADT)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:LYNN
Last Name:HAGER
Suffix:
Gender:F
Credentials:ADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 272
Mailing Address - Street 2:
Mailing Address - City:BALATON
Mailing Address - State:MN
Mailing Address - Zip Code:56115-0272
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 DREW AVE SE
Practice Address - Street 2:SUITE 202
Practice Address - City:MADELIA
Practice Address - State:MN
Practice Address - Zip Code:56062-1873
Practice Address - Country:US
Practice Address - Phone:507-642-8742
Practice Address - Fax:507-642-2926
Is Sole Proprietor?:No
Enumeration Date:2008-11-04
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH7202124Q00000X
MNDT5125K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125K00000XDental ProvidersAdvanced Practice Dental Therapist
No124Q00000XDental ProvidersDental Hygienist