Provider Demographics
NPI:1942813183
Name:KOPONEN, JESSICA L (OTR)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:KOPONEN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:L
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:1702 UNIVERSITY DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4940
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:275 11TH ST S
Practice Address - Street 2:
Practice Address - City:WAHPETON
Practice Address - State:ND
Practice Address - Zip Code:58075-4655
Practice Address - Country:US
Practice Address - Phone:701-642-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-27
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5788225X00000X
225X00000X
ND1801225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist