MEDICARE: JESSIKA MAE VIOLA WHEELER MOT, OTR/L, CLT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	105445	MN

General Provider Information

NPI Number	:	1316457989
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSIKA MAE VIOLA WHEELER MOT, OTR/L, CLT

Provider Business Mailing Address
First Line	:	108 OWENS ST S
Second Line	:
City	:	STILLWATER
State	:	MN
Zip	:	55082-5637
Country	:	US
Telephone Number	:	206-948-0551
Fax Number	:

Provider Business Practice Location Address
First Line	:	480 HIGHWAY 96 E STE 120
Second Line	:
City	:	VADNAIS HEIGHTS
State	:	MN
Zip	:	55127-2557
Country	:	US
Telephone Number	:	848-665-1482
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/09/2017
Last Update Date	:	11/10/2022

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