Provider Demographics
NPI:1164648028
Name:RIORDAN-JAESCHKE, KELLY ANN (MS CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANN
Last Name:RIORDAN-JAESCHKE
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:RIORDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:698 ROY ST S
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-1424
Mailing Address - Country:US
Mailing Address - Phone:651-699-5181
Mailing Address - Fax:
Practice Address - Street 1:80 MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:LITTLE CANADA
Practice Address - State:MN
Practice Address - Zip Code:55117-1781
Practice Address - Country:US
Practice Address - Phone:651-481-8040
Practice Address - Fax:651-481-8649
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7026235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN01126361OtherASHA MEMBER NUMBER
MN7026OtherSTATE LICENSE