Provider Demographics
NPI:1245665744
Name:EDWARDS, JEAN ANNA (MST CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:ANNA
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:MST CCC-SLP
Other - Prefix:
Other - First Name:JEAN
Other - Middle Name:ANNA
Other - Last Name:PONGRATZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:701 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW RICHMOND
Mailing Address - State:WI
Mailing Address - Zip Code:54017-2399
Mailing Address - Country:US
Mailing Address - Phone:715-243-1615
Mailing Address - Fax:
Practice Address - Street 1:701 E 11TH ST
Practice Address - Street 2:
Practice Address - City:NEW RICHMOND
Practice Address - State:WI
Practice Address - Zip Code:54017-2399
Practice Address - Country:US
Practice Address - Phone:715-243-1615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-04
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1998-154235Z00000X, 235500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235500000XSpeech, Language and Hearing Service ProvidersSpecialist/Technologist
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist