Provider Demographics
NPI:1972905495
Name:DUTTON, JESSICA (ATC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DUTTON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BIRCHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-1604
Mailing Address - Country:US
Mailing Address - Phone:651-249-3622
Mailing Address - Fax:
Practice Address - Street 1:5 BIRCHWOOD AVE
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-1604
Practice Address - Country:US
Practice Address - Phone:651-249-3622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-17
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN25052255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer