Provider Demographics
NPI:1730905191
Name:SHIELDS, JESSICA SLECK (SLP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:SLECK
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10513 UTAH RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55438-2017
Mailing Address - Country:US
Mailing Address - Phone:612-875-1792
Mailing Address - Fax:
Practice Address - Street 1:10513 UTAH RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55438-2017
Practice Address - Country:US
Practice Address - Phone:612-875-1792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN528969235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist