Provider Demographics
NPI:1457865636
Name:WILSON, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 FORDING ISLAND ROAD EXT
Mailing Address - Street 2:
Mailing Address - City:HILTON HEAD ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29926-1154
Mailing Address - Country:US
Mailing Address - Phone:608-295-7093
Mailing Address - Fax:
Practice Address - Street 1:3039 OKATIE HWY
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29909-5101
Practice Address - Country:US
Practice Address - Phone:843-705-8220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2825225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant