Provider Demographics
NPI:1265655807
Name:WILDAU, JENNIKA (LAC, DIPL AC)
Entity Type:Individual
Prefix:MS
First Name:JENNIKA
Middle Name:
Last Name:WILDAU
Suffix:
Gender:F
Credentials:LAC, DIPL AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11561 W 107TH PL
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80021-3540
Mailing Address - Country:US
Mailing Address - Phone:720-352-3722
Mailing Address - Fax:303-543-7007
Practice Address - Street 1:1697 COALTON RD
Practice Address - Street 2:SUITE C
Practice Address - City:SUPERIOR
Practice Address - State:CO
Practice Address - Zip Code:80027-4646
Practice Address - Country:US
Practice Address - Phone:720-352-3722
Practice Address - Fax:303-543-7007
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO734171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist