Healthcare Provider Details

I. General information

NPI: 1770413890
Provider Name (Legal Business Name): JESSICA BETTY ALLISON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2202 AZTEC LN
MENDOTA HEIGHTS MN
55120-1609
US

IV. Provider business mailing address

2202 AZTEC LN
MENDOTA HEIGHTS MN
55120-1609
US

V. Phone/Fax

Practice location:
  • Phone: 651-252-7380
  • Fax:
Mailing address:
  • Phone: 651-252-7380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number103773
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: