Provider Demographics
NPI:1780358317
Name:FORNWALD, JASON VITUS (EDS, MS CCC-SLP)
Entity type:Individual
Prefix:PROF
First Name:JASON
Middle Name:VITUS
Last Name:FORNWALD
Suffix:
Gender:M
Credentials:EDS, MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 S 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-6902
Mailing Address - Country:US
Mailing Address - Phone:605-336-7561
Mailing Address - Fax:605-330-9820
Practice Address - Street 1:520 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-6902
Practice Address - Country:US
Practice Address - Phone:605-336-7561
Practice Address - Fax:605-330-9820
Is Sole Proprietor?:No
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist