Provider Demographics
NPI:1164707543
Name:VANDENBERG, JENNIFER (MS, CFY-SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:VANDENBERG
Suffix:
Gender:F
Credentials:MS, CFY-SLP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:BADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CFY-SLP
Mailing Address - Street 1:2501 W 26TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-2446
Mailing Address - Country:US
Mailing Address - Phone:605-444-9500
Mailing Address - Fax:605-444-9701
Practice Address - Street 1:1020 W 18TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-4707
Practice Address - Country:US
Practice Address - Phone:605-444-9700
Practice Address - Fax:605-444-9706
Is Sole Proprietor?:No
Enumeration Date:2011-10-17
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3618235Z00000X
SD707-SLP235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3618OtherWISCONSIN LICENSE