Provider Demographics
NPI:1598180366
Name:PETERSEN, JAIME (OTR/L)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:PETERSEN
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 1:728 HERITAGE LN
Mailing Address - Street 2:
Mailing Address - City:BELLE PLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:56011-2196
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:640 3RD ST
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MN
Practice Address - Zip Code:55334-2297
Practice Address - Country:US
Practice Address - Phone:507-237-8730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-03
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103337225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist