Provider Demographics
NPI:1679664296
Name:FOSSUM, JANA LYNN (OTR L)
Entity Type:Individual
Prefix:MRS
First Name:JANA
Middle Name:LYNN
Last Name:FOSSUM
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 1:17740 71ST AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-4012
Mailing Address - Country:US
Mailing Address - Phone:612-386-7131
Mailing Address - Fax:
Practice Address - Street 1:1891 STATION PKWY NW
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-4259
Practice Address - Country:US
Practice Address - Phone:763-755-4275
Practice Address - Fax:763-755-4261
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102082225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist