Provider Demographics
NPI:1417535808
Name:WILSON, JOLYNA (MSPT)
Entity Type:Individual
Prefix:
First Name:JOLYNA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:MT
Mailing Address - Zip Code:59922-9712
Mailing Address - Country:US
Mailing Address - Phone:303-475-2504
Mailing Address - Fax:
Practice Address - Street 1:366 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:MT
Practice Address - Zip Code:59922-9712
Practice Address - Country:US
Practice Address - Phone:303-475-2504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT19503225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist