Individual
JESSICA PROVOST
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1686 EISENHOWER RD, DE PERE, WI 54115-8145
(920) 496-4700
Mailing address
8170 33RD AVE S, MAIL STOP 21110Q, MINNEAPOLIS, MN 55425-4516
(952) 883-6212
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
5422
WI
235Z00000X
Speech-Language Pathologist
9673
MN
Other
Enumeration date
06/17/2016
Last updated
02/15/2022
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