Provider Demographics
NPI:1962535245
Name:DEZALE, JODI LYNN (MA CCC SLP)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:LYNN
Last Name:DEZALE
Suffix:
Gender:F
Credentials:MA CCC SLP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3915 GOLDEN VALLEY ROAD
Mailing Address - Street 2:COURAGE CENTER
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4298
Mailing Address - Country:US
Mailing Address - Phone:763-520-0714
Mailing Address - Fax:763-520-0355
Practice Address - Street 1:3915 GOLDEN VALLEY ROAD
Practice Address - Street 2:COURAGE CENTER
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-4298
Practice Address - Country:US
Practice Address - Phone:763-520-0714
Practice Address - Fax:763-520-0355
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN7929235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN083HIDEOtherBCBS MINNESOTA
MN4600930OtherMEDICA
MNHP56680OtherHEALTHPARTNERS