Provider Demographics
NPI:1649584830
Name:ERICKSON, JENNIFER (SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14130 23RD AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-4904
Mailing Address - Country:US
Mailing Address - Phone:763-383-7666
Mailing Address - Fax:
Practice Address - Street 1:14130 23RD AVE N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-4904
Practice Address - Country:US
Practice Address - Phone:763-383-7666
Practice Address - Fax:763-383-6013
Is Sole Proprietor?:No
Enumeration Date:2010-07-30
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8670235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist