Provider Demographics
NPI:1033389705
Name:CULLEN, JENNIFER LARA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LARA
Last Name:CULLEN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2933 37TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-4103
Mailing Address - Country:US
Mailing Address - Phone:612-308-5573
Mailing Address - Fax:
Practice Address - Street 1:327 S MARSCHALL RD
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-1687
Practice Address - Country:US
Practice Address - Phone:612-807-3723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-09
Last Update Date:2008-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7480235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist