Provider Demographics
NPI:1790865384
Name:BECKER-PUKLICH, JANELLE ALISE (DC)
Entity type:Individual
Prefix:DR
First Name:JANELLE
Middle Name:ALISE
Last Name:BECKER-PUKLICH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7975 STONE CREEK DRIVE
Mailing Address - Street 2:#20
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317
Mailing Address - Country:US
Mailing Address - Phone:952-746-8150
Mailing Address - Fax:952-746-8152
Practice Address - Street 1:7975 STONE CREEK DRIVE
Practice Address - Street 2:#20
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317
Practice Address - Country:US
Practice Address - Phone:952-746-8150
Practice Address - Fax:952-746-8252
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3321111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN937319500Medicaid
MN4C861BEOtherBCBS PROVIDER NUMBER
MN4C861BEOtherBCBS PROVIDER NUMBER
MNU60812Medicare UPIN