1255490447 NPI number — MS. JENNIFER LYNN RESIDE AU.D., CCC-A

Table of content: MS. JENNIFER LYNN RESIDE AU.D., CCC-A (NPI 1255490447)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255490447 NPI number — MS. JENNIFER LYNN RESIDE AU.D., CCC-A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RESIDE
Provider First Name:
JENNIFER
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
AU.D., CCC-A
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255490447
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 STATE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARIBAULT
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55021
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-334-5915
Provider Business Mailing Address Fax Number:
507-332-6683

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 STATE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARIBAULT
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-334-5915
Provider Business Practice Location Address Fax Number:
507-332-6683
Provider Enumeration Date:
12/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 237600000X , with the licence number:  7922 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 231H00000X , with the licence number: 7922 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 640000378 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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