Basic Information
Provider Information | |||||||||
NPI: | 1457888109 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SOPER | ||||||||
FirstName: | JAMIE | ||||||||
MiddleName: | BROST | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | AU.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BROST | ||||||||
OtherFirstName: | JAMIE | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1604 WIMBLETON WAY | ||||||||
Address2: |   | ||||||||
City: | WAUNAKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 535972010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6082066974 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2710 SAINT FRANCIS DR STE 411 | ||||||||
Address2: |   | ||||||||
City: | WATERLOO | ||||||||
State: | IA | ||||||||
PostalCode: | 50702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3192725000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/12/2017 | ||||||||
LastUpdateDate: | 02/15/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/15/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 091933 | IA | Y |   | Speech, Language and Hearing Service Providers | Audiologist |   |
No ID Information.