Provider Demographics
NPI:1790906451
Name:DODSON, JEANINE RAE (MT)
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:RAE
Last Name:DODSON
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:JEANINE
Other - Middle Name:RAE
Other - Last Name:BRADLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MT
Mailing Address - Street 1:927 5TH ST, SO. #5
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-3349
Mailing Address - Country:US
Mailing Address - Phone:605-490-2530
Mailing Address - Fax:
Practice Address - Street 1:927 5TH ST, SO. #5
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-3349
Practice Address - Country:US
Practice Address - Phone:605-490-2530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4143109291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory