Provider Demographics
NPI:1609355924
Name:BROWN, JENNIFER RAFFERTY (OTR)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RAFFERTY
Last Name:BROWN
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 1:7714 ZANZIBAR LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-3706
Mailing Address - Country:US
Mailing Address - Phone:763-898-6480
Mailing Address - Fax:
Practice Address - Street 1:3390 ANNAPOLIS LN N STE B
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-5379
Practice Address - Country:US
Practice Address - Phone:763-898-6480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103670225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist