Provider Demographics
NPI:1316457989
Name:WHEELER, JESSIKA MAE VIOLA (MOT, OTR/L, CLT)
Entity type:Individual
Prefix:
First Name:JESSIKA
Middle Name:MAE VIOLA
Last Name:WHEELER
Suffix:
Gender:F
Credentials:MOT, OTR/L, CLT
Other - Prefix:
Other - First Name:JESSIKA
Other - Middle Name:MAE VIOLA
Other - Last Name:LACKIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT, OTR/L, CLT
Mailing Address - Street 1:108 OWENS ST S
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-5637
Mailing Address - Country:US
Mailing Address - Phone:206-948-0551
Mailing Address - Fax:
Practice Address - Street 1:480 HIGHWAY 96 E STE 120
Practice Address - Street 2:
Practice Address - City:VADNAIS HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55127-2557
Practice Address - Country:US
Practice Address - Phone:848-665-1482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-09
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105445225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist