Provider Demographics
NPI:1558587063
Name:MATTHEWS, JENNIFER KATHLEEN (OTR)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KATHLEEN
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8370 DELANEY DR
Mailing Address - Street 2:
Mailing Address - City:INVER GROVE HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55076-2645
Mailing Address - Country:US
Mailing Address - Phone:651-451-2663
Mailing Address - Fax:651-793-3213
Practice Address - Street 1:324 JOHNSON PKWY
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-6412
Practice Address - Country:US
Practice Address - Phone:651-793-3225
Practice Address - Fax:651-793-3213
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102353225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN245260AMedicare ID - Type UnspecifiedPROVIDER NUMBER