Provider Demographics
NPI:1629860093
Name:OTTERSTATTER, JACQUELINE (RN)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:OTTERSTATTER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:DAMBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2410 DOWNING AVE
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-4544
Mailing Address - Country:US
Mailing Address - Phone:612-709-8126
Mailing Address - Fax:
Practice Address - Street 1:14000 FAIRVIEW DR
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-5713
Practice Address - Country:US
Practice Address - Phone:952-993-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-20
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2490796163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse