Provider Demographics
NPI:1962679324
Name:SPANN, JENNIFER (SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SPANN
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:S3921 BAKKOM RD
Mailing Address - Street 2:
Mailing Address - City:VIROQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54665-8163
Mailing Address - Country:US
Mailing Address - Phone:608-637-8759
Mailing Address - Fax:
Practice Address - Street 1:101 SUNSHINE BLVD
Practice Address - Street 2:
Practice Address - City:SOLDIERS GROVE
Practice Address - State:WI
Practice Address - Zip Code:54655-7106
Practice Address - Country:US
Practice Address - Phone:608-624-5244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2773-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist