Provider Demographics
NPI:1790919231
Name:WIESNER, JAMIE MARIE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:MARIE
Last Name:WIESNER
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 1:308 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRANDT
Mailing Address - State:SD
Mailing Address - Zip Code:57218-2010
Mailing Address - Country:US
Mailing Address - Phone:605-876-3481
Mailing Address - Fax:
Practice Address - Street 1:308 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRANDT
Practice Address - State:SD
Practice Address - Zip Code:57218-2010
Practice Address - Country:US
Practice Address - Phone:605-876-3481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-12
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0588225X00000X
MN103448225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist