Provider Demographics
NPI:1235474917
Name:WILSON, JENNIFER M
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:M
Last Name:WILSON
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 1:2 HEMLOCK DR.
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902
Mailing Address - Country:US
Mailing Address - Phone:203-964-9646
Mailing Address - Fax:203-964-9646
Practice Address - Street 1:2 HEMLOCK DR
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-1811
Practice Address - Country:US
Practice Address - Phone:203-964-9646
Practice Address - Fax:203-964-9646
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-06
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002096225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology