Provider Demographics
NPI:1578797189
Name:WOLTERSTORFF, JESSICA LYNN (MA CF/SLP)
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:LYNN
Last Name:WOLTERSTORFF
Suffix:
Gender:F
Credentials:MA CF/SLP
Other - Prefix:
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Mailing Address - Street 1:5200 FAIRVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MN
Mailing Address - Zip Code:55092-8013
Mailing Address - Country:US
Mailing Address - Phone:651-257-8475
Mailing Address - Fax:651-257-8437
Practice Address - Street 1:11725 STINSON AVE
Practice Address - Street 2:
Practice Address - City:CHISAGO CITY
Practice Address - State:MN
Practice Address - Zip Code:55013-9542
Practice Address - Country:US
Practice Address - Phone:651-257-8475
Practice Address - Fax:651-257-8437
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8422235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist