Provider Demographics
NPI:1750528824
Name:CONNELLY, JANE F (AUD CCC-A)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:F
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:AUD CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 WILDWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55110-1619
Mailing Address - Country:US
Mailing Address - Phone:651-426-7658
Mailing Address - Fax:
Practice Address - Street 1:560 CONCORDIA AVE
Practice Address - Street 2:RONDO ECSE
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55103-2443
Practice Address - Country:US
Practice Address - Phone:651-325-2699
Practice Address - Fax:651-325-2691
Is Sole Proprietor?:No
Enumeration Date:2009-01-12
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5330231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist