Provider Demographics
NPI:1083083208
Name:FOSSEN, JESSICA (DPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:FOSSEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-4667
Mailing Address - Country:US
Mailing Address - Phone:701-857-5105
Mailing Address - Fax:701-857-5646
Practice Address - Street 1:101 3RD AVE SW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-3880
Practice Address - Country:US
Practice Address - Phone:701-857-5286
Practice Address - Fax:701-857-5694
Is Sole Proprietor?:No
Enumeration Date:2015-09-17
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2036225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist