Provider Demographics
NPI:1578717112
Name:GUSTAFSON, JENNIFER (OT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12057 411TH AVE
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:SD
Mailing Address - Zip Code:57432-7302
Mailing Address - Country:US
Mailing Address - Phone:605-290-1163
Mailing Address - Fax:
Practice Address - Street 1:12057 411TH AVE
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:SD
Practice Address - Zip Code:57432-7302
Practice Address - Country:US
Practice Address - Phone:605-290-1163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-10
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0487225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1041741OtherCERTIFICATION