Provider Demographics
NPI:1790817203
Name:JEDLICKA, KIMBERLY DAWN (OD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:DAWN
Last Name:JEDLICKA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 DAKOTA PT
Mailing Address - Street 2:
Mailing Address - City:JORDAN
Mailing Address - State:MN
Mailing Address - Zip Code:55352-1441
Mailing Address - Country:US
Mailing Address - Phone:952-492-3135
Mailing Address - Fax:
Practice Address - Street 1:223 1ST ST E
Practice Address - Street 2:SUITE 101
Practice Address - City:JORDAN
Practice Address - State:MN
Practice Address - Zip Code:55352-1561
Practice Address - Country:US
Practice Address - Phone:952-492-2350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2632152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist