Provider Demographics
NPI:1508483108
Name:WICKMAN, JENNA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:WICKMAN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1377 MOTOR PKWY STE 307
Mailing Address - Street 2:
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749-5258
Mailing Address - Country:US
Mailing Address - Phone:631-580-5200
Mailing Address - Fax:631-760-8306
Practice Address - Street 1:3253 TAYLOR RD STE 200
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-2452
Practice Address - Country:US
Practice Address - Phone:757-881-1137
Practice Address - Fax:757-881-1138
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305213611225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist