Provider Demographics
NPI:1598343832
Name:WIERWILLE, JENNIFER (COTA/L)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WIERWILLE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 SE 5TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-3822
Mailing Address - Country:US
Mailing Address - Phone:316-871-9059
Mailing Address - Fax:
Practice Address - Street 1:1021 CEDARS DR
Practice Address - Street 2:
Practice Address - City:MCPHERSON
Practice Address - State:KS
Practice Address - Zip Code:67460-2735
Practice Address - Country:US
Practice Address - Phone:620-241-0919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-01750224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS18-01750OtherKS STATE BOARD OF HEALING ARTS