Provider Demographics
NPI:1275595050
Name:WILD, JILL CHRISTINE (MPT)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:CHRISTINE
Last Name:WILD
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:396 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08048-9566
Mailing Address - Country:US
Mailing Address - Phone:267-614-1810
Mailing Address - Fax:
Practice Address - Street 1:396 MAIN ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NJ
Practice Address - Zip Code:08048-9566
Practice Address - Country:US
Practice Address - Phone:267-614-1810
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01169500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist