Provider Demographics
NPI:1548563000
Name:LEYENDECKER, JASON RYAN (AUD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:RYAN
Last Name:LEYENDECKER
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6444 XERXES AVE S
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55423-1039
Mailing Address - Country:US
Mailing Address - Phone:952-831-4222
Mailing Address - Fax:952-831-4942
Practice Address - Street 1:6444 XERXES AVE S
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55423-1039
Practice Address - Country:US
Practice Address - Phone:952-831-4222
Practice Address - Fax:952-831-4942
Is Sole Proprietor?:No
Enumeration Date:2010-12-06
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8450231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN8450OtherSTATE OF MINNESOTA LICENSE