Provider Demographics
NPI:1194176388
Name:WILLS, JESSICA (OTR/L)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WILLS
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 1:4352 PICKWICK CIR
Mailing Address - Street 2:APARTMENT E119
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-3134
Mailing Address - Country:US
Mailing Address - Phone:763-221-0422
Mailing Address - Fax:
Practice Address - Street 1:11606 WAYZATA BLVD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-2009
Practice Address - Country:US
Practice Address - Phone:952-544-0349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-29
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104131225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist