Provider Demographics
NPI:1689820268
Name:WIGGINS, JEFFERSON (PT)
Entity Type:Individual
Prefix:MR
First Name:JEFFERSON
Middle Name:
Last Name:WIGGINS
Suffix:
Gender:M
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:PO BOX 1865
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48121
Mailing Address - Country:US
Mailing Address - Phone:313-658-0277
Mailing Address - Fax:519-736-8110
Practice Address - Street 1:24901 NORTHWESTERN HWY
Practice Address - Street 2:SUITE #113
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075
Practice Address - Country:US
Practice Address - Phone:947-282-8575
Practice Address - Fax:947-282-8576
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-14
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501006791225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist