Provider Demographics
NPI:1396867750
Name:WILD, JENNIFER L (OTR)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:L
Last Name:WILD
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10702 SW ELSINORE DR
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-2149
Mailing Address - Country:US
Mailing Address - Phone:772-336-6928
Mailing Address - Fax:
Practice Address - Street 1:1483 SW BOUGAINVILLEA AVE
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-7302
Practice Address - Country:US
Practice Address - Phone:772-336-6928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-05
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT8477225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL884456900Medicaid