Provider Demographics
NPI:1780107946
Name:CARLSON, JENNIFER ANNETTE (CFY)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANNETTE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:CFY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56278-1357
Mailing Address - Country:US
Mailing Address - Phone:320-839-4090
Mailing Address - Fax:320-839-4196
Practice Address - Street 1:15620 EDGEWOOD DR STE 240
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56401-6984
Practice Address - Country:US
Practice Address - Phone:218-454-7012
Practice Address - Fax:218-454-7015
Is Sole Proprietor?:No
Enumeration Date:2017-07-19
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9929235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist