Provider Demographics
NPI:1952396111
Name:JANZEN, JODINE L (OD)
Entity type:Individual
Prefix:
First Name:JODINE
Middle Name:L
Last Name:JANZEN
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 1:120 1ST AVE E
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:55008-1209
Mailing Address - Country:US
Mailing Address - Phone:763-689-1494
Mailing Address - Fax:763-691-8395
Practice Address - Street 1:120 1ST AVE E
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008-1209
Practice Address - Country:US
Practice Address - Phone:763-689-1494
Practice Address - Fax:763-691-8395
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2586152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN410047970OtherRAILROAD MEDICARE
MN1014827OtherPREFERRED ONE
MN64G67JAOtherBLUECROSS BLUESHIELD
MN321025100Medicaid
MN2201810OtherMEDICA
MN410047970OtherRAILROAD MEDICARE
MN410001808Medicare PIN