Provider Demographics
NPI:1437349628
Name:HYSTEAD, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:HYSTEAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 SPRING ST APT 218
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-4461
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3000 WHITE BEAR AVE N STE 28
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1324
Practice Address - Country:US
Practice Address - Phone:651-770-8884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8046235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist