Provider Demographics
NPI:1043217433
Name:JIMMY G. ANDERSON, D.C.
Entity type:Organization
Organization Name:JIMMY G. ANDERSON, D.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:G
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-777-9757
Mailing Address - Street 1:BOX 831
Mailing Address - Street 2:3394 LAKE ELMO AVENUE NORTH
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
Practice Address - Street 2:
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1217111N00000X
KY3048111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN20135ANOtherBCBS
MNON362ANOtherBCBS
MN766225400Medicaid
350002316Medicare ID - Type Unspecified
MNON362ANOtherBCBS