Provider Demographics
NPI:1962691659
Name:VAGSTAD, JANE ADAMS (OTR)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:ADAMS
Last Name:VAGSTAD
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:ADAMS
Other - Last Name:VAGSTAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR
Mailing Address - Street 1:364 CATHERINE ST APT F3
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-3050
Mailing Address - Country:US
Mailing Address - Phone:509-525-9578
Mailing Address - Fax:
Practice Address - Street 1:364 CATHERINE ST APT F3
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-3050
Practice Address - Country:US
Practice Address - Phone:509-525-9578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-18
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0001840225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist