Provider Demographics
NPI:1801041447
Name:BOSSHART, JACKIE LYNN (OTR/L)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:LYNN
Last Name:BOSSHART
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 1:710 COMMERCE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-4925
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10230 BALTIMORE ST NE STE 300
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-4674
Practice Address - Country:US
Practice Address - Phone:651-968-5201
Practice Address - Fax:651-968-5903
Is Sole Proprietor?:No
Enumeration Date:2008-11-24
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103609225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist