Provider Demographics
NPI:1659850550
Name:VILLERY, JESSICA KELLY (OTD, OTR/L)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:KELLY
Last Name:VILLERY
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:DR
Other - First Name:JESSICA
Other - Middle Name:KELLY
Other - Last Name:TRYHUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTD, OTR/L
Mailing Address - Street 1:9400 ZANE AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-1814
Mailing Address - Country:US
Mailing Address - Phone:763-762-8800
Mailing Address - Fax:763-315-4669
Practice Address - Street 1:120 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-3501
Practice Address - Country:US
Practice Address - Phone:507-322-5464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-10
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105740225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist