Provider Demographics
NPI:1235412412
Name:WILDE, JENNIFER L (DPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:WILDE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 MADISON ST
Mailing Address - Street 2:SUITE 901
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-1172
Mailing Address - Country:US
Mailing Address - Phone:206-264-8100
Mailing Address - Fax:206-264-8689
Practice Address - Street 1:510 8TH AVE NE
Practice Address - Street 2:SUITE 340
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98029-5436
Practice Address - Country:US
Practice Address - Phone:425-313-3055
Practice Address - Fax:425-313-3051
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
WAPT60293716225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No172V00000XOther Service ProvidersCommunity Health Worker