Provider Demographics
NPI:1316362148
Name:WILCOX, KRISTEN
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:WILCOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:90 HOWARD DR
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-8138
Mailing Address - Country:US
Mailing Address - Phone:502-633-1007
Mailing Address - Fax:503-437-0624
Practice Address - Street 1:90 HOWARD DR
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-8138
Practice Address - Country:US
Practice Address - Phone:502-633-1007
Practice Address - Fax:503-437-0624
Is Sole Proprietor?:No
Enumeration Date:2014-03-04
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH008557225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2187155Medicaid
OHAB7360731Medicare PIN