Provider Demographics
NPI:1194012724
Name:LEADHOLM, JESSICA E (MSCFYSLP)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:E
Last Name:LEADHOLM
Suffix:
Gender:F
Credentials:MSCFYSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 MILTON ST N APT 105
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-7029
Mailing Address - Country:US
Mailing Address - Phone:651-587-4896
Mailing Address - Fax:
Practice Address - Street 1:77 MILTON ST N APT 105
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-7029
Practice Address - Country:US
Practice Address - Phone:651-587-4896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-04
Last Update Date:2011-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3487-154235Z00000X
MN8729235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist