Provider Demographics
NPI:1053088245
Name:JENICKE, DOROTHY LEE (STUDENT)
Entity type:Individual
Prefix:
First Name:DOROTHY
Middle Name:LEE
Last Name:JENICKE
Suffix:
Gender:F
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:946 HAWTHORNE AVE E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-2012
Mailing Address - Country:US
Mailing Address - Phone:989-289-5997
Mailing Address - Fax:
Practice Address - Street 1:8053 E BLOOMINGTON FWY
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-4577
Practice Address - Country:US
Practice Address - Phone:612-333-2155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program