Provider Demographics
NPI:1215144654
Name:ADVANCE SPEECH THERAPY, LLC
Entity type:Organization
Organization Name:ADVANCE SPEECH THERAPY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:M
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:651-784-7007
Mailing Address - Street 1:6776 LAKE DR
Mailing Address - Street 2:220
Mailing Address - City:LINO LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:55014-1191
Mailing Address - Country:US
Mailing Address - Phone:651-784-7007
Mailing Address - Fax:651-784-7992
Practice Address - Street 1:6776 LAKE DR
Practice Address - Street 2:220
Practice Address - City:LINO LAKES
Practice Address - State:MN
Practice Address - Zip Code:55014
Practice Address - Country:US
Practice Address - Phone:651-784-7007
Practice Address - Fax:651-784-7992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7350235Z00000X
MN8361235Z00000X
MN8679235Z00000X
MN8826235Z00000X
MN8490235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN073222200Medicaid