Provider Demographics
NPI:1114553369
Name:HEIDERSCHEIT, JONATHAN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:HEIDERSCHEIT
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8801 JASMINE LN
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3913
Mailing Address - Country:US
Mailing Address - Phone:563-568-1066
Mailing Address - Fax:
Practice Address - Street 1:15160 FOLIAGE AVE # 170
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-5916
Practice Address - Country:US
Practice Address - Phone:952-683-1745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-19
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist