Provider Demographics
NPI:1447553011
Name:DEFORE, JENNIFER ROSE (OTR/L)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROSE
Last Name:DEFORE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-9118
Mailing Address - Country:US
Mailing Address - Phone:651-424-4034
Mailing Address - Fax:
Practice Address - Street 1:721 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-9118
Practice Address - Country:US
Practice Address - Phone:651-424-4034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-21
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103934225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist