Provider Demographics
NPI:1417558859
Name:ZEGLOVITCH, JACK YOUNG
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:YOUNG
Last Name:ZEGLOVITCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 7TH ST W APT 6
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-4230
Mailing Address - Country:US
Mailing Address - Phone:651-815-5037
Mailing Address - Fax:
Practice Address - Street 1:1800 2ND ST NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55418-4306
Practice Address - Country:US
Practice Address - Phone:612-789-1236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist