Provider Demographics
NPI:1972178259
Name:BASMAN, JENNA PAIGE
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:PAIGE
Last Name:BASMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:569 WILLOUGHBY WAY E
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-5414
Mailing Address - Country:US
Mailing Address - Phone:763-232-2931
Mailing Address - Fax:
Practice Address - Street 1:569 WILLOUGHBY WAY E
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-5414
Practice Address - Country:US
Practice Address - Phone:763-232-2931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist