Healthcare Provider Details

I. General information

NPI: 1285554964
Provider Name (Legal Business Name): JALEN GRACE TAYLOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4575 23RD AVE S STE 400
FARGO ND
58104-8783
US

IV. Provider business mailing address

4482 45TH ST N
FARGO ND
58102-6916
US

V. Phone/Fax

Practice location:
  • Phone: 701-347-1782
  • Fax:
Mailing address:
  • Phone: 320-267-3214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number2309
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: