Provider Demographics
NPI:1558541391
Name:WICHTERMAN, JENNIFER L (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:WICHTERMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 KAMOKILA BLVD
Mailing Address - Street 2:SUITE 114
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-2097
Mailing Address - Country:US
Mailing Address - Phone:808-674-0500
Mailing Address - Fax:808-674-0511
Practice Address - Street 1:99-128 AIEA HEIGHTS DRIVE
Practice Address - Street 2:SUITE 114
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-3968
Practice Address - Country:US
Practice Address - Phone:808-487-0487
Practice Address - Fax:808-486-8674
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-09
Last Update Date:2015-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7865225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0446631Medicaid
TN446631Medicare PIN