Provider Demographics
NPI:1316727753
Name:SHANKS, JORDYN (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JORDYN
Middle Name:
Last Name:SHANKS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 MARSH ST
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-4752
Mailing Address - Country:US
Mailing Address - Phone:507-625-4031
Mailing Address - Fax:
Practice Address - Street 1:1400 MADISON AVE STE 100AA
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5465
Practice Address - Country:US
Practice Address - Phone:507-594-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-03
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
MN528766235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist