Provider Demographics
NPI:1659918654
Name:VETTEL, JENNIFER K (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:K
Last Name:VETTEL
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4578 DENBIGH RD
Mailing Address - Street 2:
Mailing Address - City:MOUND
Mailing Address - State:MN
Mailing Address - Zip Code:55364-1906
Mailing Address - Country:US
Mailing Address - Phone:612-396-6302
Mailing Address - Fax:
Practice Address - Street 1:4578 DENBIGH RD
Practice Address - Street 2:
Practice Address - City:MOUND
Practice Address - State:MN
Practice Address - Zip Code:55364-1906
Practice Address - Country:US
Practice Address - Phone:612-396-6302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6052235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist