Healthcare Provider Details

I. General information

NPI: 1730905191
Provider Name (Legal Business Name): JESSICA SLECK SHIELDS SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2024
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 W BROADWAY AVE
MINNEAPOLIS MN
55411-2533
US

IV. Provider business mailing address

10513 UTAH RD
BLOOMINGTON MN
55438-2017
US

V. Phone/Fax

Practice location:
  • Phone: 612-668-0254
  • Fax:
Mailing address:
  • Phone: 612-875-1792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number528969
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: