1619017795 NPI number — JENNIFER FLESCHE MACCCSLP

Table of content: JENNIFER FLESCHE MACCCSLP (NPI 1619017795)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619017795 NPI number — JENNIFER FLESCHE MACCCSLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FLESCHE
Provider First Name:
JENNIFER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MACCCSLP
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:
1619017795
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4058 DEERWOOD TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAGAN
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55122-1889
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-994-9644
Provider Business Mailing Address Fax Number:
651-994-8962

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14635 PENNOCK AVE
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
APPLE VALLEY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55124-6430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-997-2823
Provider Business Practice Location Address Fax Number:
952-997-6931
Provider Enumeration Date:
02/07/2007

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: 235Z00000X , with the licence number:  7007 , 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: 96359F1 . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 123448000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4600874 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP34799 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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