Provider Demographics
NPI:1083223309
Name:WAHL, JENNIFER SUE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUE
Last Name:WAHL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 4TH ST S
Mailing Address - Street 2:
Mailing Address - City:NORTHWOOD
Mailing Address - State:IA
Mailing Address - Zip Code:50459-1900
Mailing Address - Country:US
Mailing Address - Phone:641-390-0319
Mailing Address - Fax:
Practice Address - Street 1:308 4TH ST S
Practice Address - Street 2:
Practice Address - City:NORTHWOOD
Practice Address - State:IA
Practice Address - Zip Code:50459-1900
Practice Address - Country:US
Practice Address - Phone:641-390-0319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA088886225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty