Provider Demographics
NPI:1508133190
Name:DEFORREST, JESSICA (MA, ATC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DEFORREST
Suffix:
Gender:F
Credentials:MA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 HICKORY LN N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-7037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4080 W BROADWAY AVE STE 300
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-5607
Practice Address - Country:US
Practice Address - Phone:651-231-8379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-26
Last Update Date:2011-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN17552255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer