Provider Demographics
NPI:1801115712
Name:DULKA, JACQUELYN (MOT, OTR/L)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:DULKA
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:
Other - Last Name:RICHARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MOT, OTR/L
Mailing Address - Street 1:4342 15TH AVE S STE 105
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1125
Mailing Address - Country:US
Mailing Address - Phone:701-936-9495
Mailing Address - Fax:952-222-1994
Practice Address - Street 1:4342 15TH AVE S STE 105
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1125
Practice Address - Country:US
Practice Address - Phone:701-936-9495
Practice Address - Fax:952-222-1994
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-18
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103637225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist