Provider Demographics
NPI:1437305604
Name:WILD, JENNIFER A (SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:WILD
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 LOTHROP ST
Mailing Address - Street 2:FORBES TOWER, ROOM 9055
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15213-2536
Mailing Address - Country:US
Mailing Address - Phone:412-647-3087
Mailing Address - Fax:412-647-4486
Practice Address - Street 1:200 LOTHROP ST
Practice Address - Street 2:EEI, SUITE 215
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213-2536
Practice Address - Country:US
Practice Address - Phone:412-647-8093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-07
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL009145231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA169540EN4Medicare PIN