Provider Demographics
NPI:1952786576
Name:CONNOLLY RUSSOW, JESSICA BETH (AUD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:BETH
Last Name:CONNOLLY RUSSOW
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:BETH
Other - Last Name:CONNOLLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4225 NATHAN LN N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-1633
Mailing Address - Country:US
Mailing Address - Phone:612-619-3987
Mailing Address - Fax:
Practice Address - Street 1:3800 PARK NICOLLET BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2527
Practice Address - Country:US
Practice Address - Phone:952-993-3123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-24
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
9519231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist