Provider Demographics
NPI:1477037752
Name:MATTESON LAABS, JENNA MARIE (MAOT, OTR/L)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:MARIE
Last Name:MATTESON LAABS
Suffix:
Gender:F
Credentials:MAOT, OTR/L
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:MARIE
Other - Last Name:MATTESON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:399 ELM ST
Mailing Address - Street 2:
Mailing Address - City:LINO LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:55014-1269
Mailing Address - Country:US
Mailing Address - Phone:763-792-5434
Mailing Address - Fax:
Practice Address - Street 1:3111 124TH AVE NW STE 123
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-4573
Practice Address - Country:US
Practice Address - Phone:763-236-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-21
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104672225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist