MEDICARE: JESSICA CHRISTINE WAN CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	10142	MN

General Provider Information

NPI Number	:	1548815525
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA CHRISTINE WAN CCC-SLP

Provider Business Mailing Address
First Line	:	3483 FAIR OAKS CT
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-4578
Country	:	US
Telephone Number	:	651-815-3752
Fax Number	:

Provider Business Practice Location Address
First Line	:	3483 FAIR OAKS CT
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-4578
Country	:	US
Telephone Number	:	651-815-3752
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/06/2019
Last Update Date	:	08/06/2019

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