Provider Demographics
NPI:1902171606
Name:ROTHER, JODI RANAE (HIS)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:RANAE
Last Name:ROTHER
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17316 KENYON AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-6909
Mailing Address - Country:US
Mailing Address - Phone:952-255-8579
Mailing Address - Fax:952-255-8578
Practice Address - Street 1:17316 KENYON AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-6909
Practice Address - Country:US
Practice Address - Phone:952-255-8579
Practice Address - Fax:952-255-8578
Is Sole Proprietor?:No
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2480174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2480OtherMN DEPARTMENT OF HEALTH