Healthcare Provider Details

I. General information

NPI: 1104767300
Provider Name (Legal Business Name): JAMIE RISDAL CCC-SLP
Entity Type: Individual
Gender:
Sole Proprietor: N

Provider Other Name: ISAAC RISDAL CCC-SLP

II. Dates (important events)

Enumeration Date: 04/02/2026
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16401 E CENTRETECH PKWY STE 2
AURORA CO
80011-9066
US

IV. Provider business mailing address

8633 DATAPOINT DR APT 268
SAN ANTONIO TX
78229-3255
US

V. Phone/Fax

Practice location:
  • Phone: 720-706-3396
  • Fax:
Mailing address:
  • Phone: 832-331-1196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number0006810
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: