Provider Demographics
NPI:1497595136
Name:WAGNER, JADALYN LANE (OTD)
Entity type:Individual
Prefix:DR
First Name:JADALYN
Middle Name:LANE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1900 SILVER LAKE RD NW STE 110
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1789
Mailing Address - Country:US
Mailing Address - Phone:651-628-9566
Mailing Address - Fax:651-628-0411
Practice Address - Street 1:20288 HIGHWAY 15 N STE 100
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:MN
Practice Address - Zip Code:55350-5685
Practice Address - Country:US
Practice Address - Phone:320-244-2437
Practice Address - Fax:320-234-6358
Is Sole Proprietor?:No
Enumeration Date:2024-05-30
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
225X00000X
MN107577225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist