Provider Demographics
NPI:1477613487
Name:CHURCH, JODI ANN (DC)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:ANN
Last Name:CHURCH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:ANN
Other - Last Name:OLESON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:1755 17TH AVE E
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-3372
Mailing Address - Country:US
Mailing Address - Phone:952-445-5250
Mailing Address - Fax:952-445-5350
Practice Address - Street 1:1755 17TH AVE E
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-3372
Practice Address - Country:US
Practice Address - Phone:952-445-5250
Practice Address - Fax:952-445-5350
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4253111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU93676Medicare UPIN
MN350002790Medicare ID - Type UnspecifiedMEDICARE