Provider Demographics
NPI:1083191829
Name:WHARTON, JENNIFER L (PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:WHARTON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2819 241ST AVE SE
Mailing Address - Street 2:
Mailing Address - City:SAMMAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98075-6026
Mailing Address - Country:US
Mailing Address - Phone:425-313-0304
Mailing Address - Fax:
Practice Address - Street 1:7454 NEWCASTLE GOLF CLUB RD
Practice Address - Street 2:
Practice Address - City:NEWCASTLE
Practice Address - State:WA
Practice Address - Zip Code:98059-9176
Practice Address - Country:US
Practice Address - Phone:425-453-1508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60087739225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant