Healthcare Provider Details

I. General information

NPI: 1790492148
Provider Name (Legal Business Name): JANA WEISMEYER TRACY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2022
Last Update Date: 11/13/2022
Certification Date: 11/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2945 LINCOLN DR
ROSEVILLE MN
55113-1338
US

IV. Provider business mailing address

525 FAIRVIEW AVE S
SAINT PAUL MN
55116-1458
US

V. Phone/Fax

Practice location:
  • Phone: 651-628-3000
  • Fax:
Mailing address:
  • Phone: 651-695-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number9069
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: