Provider Demographics
NPI:1609828474
Name:WILKS, KENDRA JAYNE (MPT)
Entity Type:Individual
Prefix:MRS
First Name:KENDRA
Middle Name:JAYNE
Last Name:WILKS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:KENDRA
Other - Middle Name:
Other - Last Name:SHAPPEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:600 S 21ST ST UNIT 130
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80904-3763
Mailing Address - Country:US
Mailing Address - Phone:719-634-1110
Mailing Address - Fax:719-634-1112
Practice Address - Street 1:600 S 21ST ST UNIT 130
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-3763
Practice Address - Country:US
Practice Address - Phone:719-634-1110
Practice Address - Fax:719-634-1112
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR62838225100000X
WAPT60131985225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WPT20250AMedicare ID - Type Unspecified