Basic Information
| Provider Information | |||||||||
| NPI: | 1255490447 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RESIDE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | AU.D., CCC-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 STATE AVE | ||||||||
| Address2: | |||||||||
| City: | FARIBAULT | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073345915 | ||||||||
| FaxNumber: | 5073326683 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 STATE AVE | ||||||||
| Address2: | |||||||||
| City: | FARIBAULT | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073345915 | ||||||||
| FaxNumber: | 5073326683 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 03/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | 7922 | MN | N | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 231H00000X | 7922 | MN | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 640000378 | 05 | MN | MEDICAID |