Provider Demographics
NPI:1326269739
Name:WILDER, JACK ANTHONY (PT)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:ANTHONY
Last Name:WILDER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4701 77TH CT SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-9697
Mailing Address - Country:US
Mailing Address - Phone:360-455-9068
Mailing Address - Fax:
Practice Address - Street 1:405 BLACK HILLS LN SW
Practice Address - Street 2:SUITE G
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8661
Practice Address - Country:US
Practice Address - Phone:360-956-2562
Practice Address - Fax:360-956-1894
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT000096192251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic