Healthcare Provider Details

I. General information

NPI: 1497595136
Provider Name (Legal Business Name): JADALYN LANE WAGNER OTD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2024
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20288 HIGHWAY 15 N STE 100
HUTCHINSON MN
55350-5685
US

IV. Provider business mailing address

1900 SILVER LAKE RD NW STE 110
NEW BRIGHTON MN
55112-1789
US

V. Phone/Fax

Practice location:
  • Phone: 320-244-2437
  • Fax: 320-234-6358
Mailing address:
  • Phone: 651-628-9566
  • Fax: 651-628-0411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number107577
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: