Provider Demographics
NPI:1942587233
Name:JOHNSON, JENNIFER L (OTR/L)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:JOHNSON
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 1:909 FULTON ST SE RM 4392
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-4800
Mailing Address - Country:US
Mailing Address - Phone:612-676-4483
Mailing Address - Fax:
Practice Address - Street 1:909 FULTON ST SE STE 4-392
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-4800
Practice Address - Country:US
Practice Address - Phone:612-676-4483
Practice Address - Fax:612-676-4039
Is Sole Proprietor?:No
Enumeration Date:2011-11-15
Last Update Date:2021-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105171225X00000X
WI4998-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist