Provider Demographics
NPI:1164807673
Name:BRADY-JOHNSON, JENNIFER (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:BRADY-JOHNSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 CHERRY HILL TRL
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55340-9317
Mailing Address - Country:US
Mailing Address - Phone:763-639-0578
Mailing Address - Fax:
Practice Address - Street 1:6625 LYNDALE AVE S
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-2373
Practice Address - Country:US
Practice Address - Phone:952-285-2840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-26
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102172174400000X
225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No174400000XOther Service ProvidersSpecialist