Provider Demographics
NPI:1407240443
Name:WHEELER, JENNIFER L (LMT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:WHEELER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2861 ASHLEY DR
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-8787
Mailing Address - Country:US
Mailing Address - Phone:734-244-6022
Mailing Address - Fax:
Practice Address - Street 1:1801 W MAUMEE ST
Practice Address - Street 2:SUITE 110
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1291
Practice Address - Country:US
Practice Address - Phone:734-244-6022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-27
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501002525171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7501002525OtherMICHIGAN LICENSE NUMBER