Healthcare Provider Details

I. General information

NPI: 1942813183
Provider Name (Legal Business Name): JESSICA L KOPONEN OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA L ANDERSON OTR

II. Dates (important events)

Enumeration Date: 08/27/2020
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 11TH ST S
WAHPETON ND
58075-4655
US

IV. Provider business mailing address

1702 UNIVERSITY DR S
FARGO ND
58103-4940
US

V. Phone/Fax

Practice location:
  • Phone: 701-642-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5788
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1801
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: