Provider Demographics
NPI:1518161231
Name:WICK, JESSICA M (DPT, CHT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:WICK
Suffix:
Gender:F
Credentials:DPT, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4202 E SAN ANGELO AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-0356
Mailing Address - Country:US
Mailing Address - Phone:314-413-1529
Mailing Address - Fax:
Practice Address - Street 1:4202 E SAN ANGELO AVE
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-0356
Practice Address - Country:US
Practice Address - Phone:314-413-1529
Practice Address - Fax:480-813-7901
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8611225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO223811509Medicare PIN
MO223811511Medicare PIN