Provider Demographics
NPI:1851687271
Name:DEZIEL, JENNIE
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:DEZIEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 ROBERT ST S
Mailing Address - Street 2:T-2046
Mailing Address - City:WEST ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55118-3919
Mailing Address - Country:US
Mailing Address - Phone:651-455-6626
Mailing Address - Fax:651-455-1903
Practice Address - Street 1:1750 ROBERT ST S
Practice Address - Street 2:T-2046
Practice Address - City:WEST ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-3919
Practice Address - Country:US
Practice Address - Phone:651-455-6626
Practice Address - Fax:651-455-1903
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN114476183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist