Provider Demographics
NPI:1689907123
Name:OLDHAM, JANE (MA, OTR/L)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:OLDHAM
Suffix:
Gender:F
Credentials:MA, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5155 E RIVER RD
Mailing Address - Street 2:SUITE 403
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55421-1025
Mailing Address - Country:US
Mailing Address - Phone:763-572-2519
Mailing Address - Fax:763-572-2616
Practice Address - Street 1:5155 E RIVER RD
Practice Address - Street 2:SUITE 403
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55421-1025
Practice Address - Country:US
Practice Address - Phone:763-572-2519
Practice Address - Fax:763-572-2616
Is Sole Proprietor?:No
Enumeration Date:2009-09-16
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103747225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist