Provider Demographics
NPI:1114110343
Name:WYCKOFF, JENNIFER (MSOTRL)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:WYCKOFF
Suffix:
Gender:F
Credentials:MSOTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 MANOR AVE
Mailing Address - Street 2:
Mailing Address - City:LANGHORNE
Mailing Address - State:PA
Mailing Address - Zip Code:19047-2943
Mailing Address - Country:US
Mailing Address - Phone:215-757-7667
Mailing Address - Fax:215-750-1426
Practice Address - Street 1:350 MANOR AVE
Practice Address - Street 2:
Practice Address - City:LANGHORNE
Practice Address - State:PA
Practice Address - Zip Code:19047-2943
Practice Address - Country:US
Practice Address - Phone:215-757-7667
Practice Address - Fax:215-750-1426
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC010096225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist