Provider Demographics
NPI:1396100376
Name:OTTS, JESSICA (RN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:OTTS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4561 SLATER RD APT 103
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-3374
Mailing Address - Country:US
Mailing Address - Phone:612-423-7412
Mailing Address - Fax:
Practice Address - Street 1:4561 SLATER RD APT 103
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-3374
Practice Address - Country:US
Practice Address - Phone:612-423-7412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-17
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN226705-8163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse