Provider Demographics
NPI:1578683629
Name:WILSON, JENNIFER C (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:C
Last Name:WILSON
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 1:6 E PALO VERDE ST STE 13
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-1020
Mailing Address - Country:US
Mailing Address - Phone:602-363-4633
Mailing Address - Fax:
Practice Address - Street 1:6 E PALO VERDE ST STE 13
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-1020
Practice Address - Country:US
Practice Address - Phone:602-363-4633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2015-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5265225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ624917Medicaid