Provider Demographics
NPI:1366489668
Name:WISE, JERI L (MPT)
Entity Type:Individual
Prefix:
First Name:JERI
Middle Name:L
Last Name:WISE
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 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:1701 N GREEN VALLEY PKWY
Practice Address - Street 2:BLDG 8, STE. B
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-5885
Practice Address - Country:US
Practice Address - Phone:702-998-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1045225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV003402035Medicaid
NV003402035Medicaid