Provider Demographics
NPI:1043323884
Name:WYLY, JENNIFER DAWN (PT, ATC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DAWN
Last Name:WYLY
Suffix:
Gender:F
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1172
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85653-1172
Mailing Address - Country:US
Mailing Address - Phone:520-954-7991
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY OF ARIZONA ATHLETIC TREATMENT CTR
Practice Address - Street 2:MCKALE CENTER RM. N108
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85721-0001
Practice Address - Country:US
Practice Address - Phone:520-621-9169
Practice Address - Fax:520-621-8771
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ02062255A2300X
AZ4254225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer