Provider Demographics
NPI:1508955451
Name:WILHAM, JENNIFER KAY (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KAY
Last Name:WILHAM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:KAY
Other - Last Name:SCHAFFENACKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:12 LAMPLIGHTER CIR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PULASKI
Mailing Address - State:IL
Mailing Address - Zip Code:62548-6060
Mailing Address - Country:US
Mailing Address - Phone:217-605-5500
Mailing Address - Fax:217-732-3101
Practice Address - Street 1:800 N. 1ST ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702
Practice Address - Country:US
Practice Address - Phone:217-528-7541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070011602225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
K17892Medicare ID - Type Unspecified