Provider Demographics
NPI:1942369871
Name:ANDERSON, JIMMY G (DC)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:G
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
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Mailing Address - Street 1:3394 LAKE ELMO AVENUE NORTH
Mailing Address - Street 2:BOX 831
Mailing Address - City:LAKE ELMO
Mailing Address - State:MN
Mailing Address - Zip Code:55042-0831
Mailing Address - Country:US
Mailing Address - Phone:651-777-9757
Mailing Address - Fax:651-777-9757
Practice Address - Street 1:3394 LAKE ELMO AVENUE NORTH
Practice Address - Street 2:BOX 831
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55042-0831
Practice Address - Country:US
Practice Address - Phone:651-777-9757
Practice Address - Fax:651-777-9757
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN1217111N00000X
KY3048111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0N362ANOtherBLUE CROSS BLUE SHIELD