Provider Demographics
NPI:1760704431
Name:WILBURN, JARED COLE (MPT)
Entity Type:Individual
Prefix:MR
First Name:JARED
Middle Name:COLE
Last Name:WILBURN
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 S LOOP RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3405
Mailing Address - Country:US
Mailing Address - Phone:859-301-2663
Mailing Address - Fax:859-301-0655
Practice Address - Street 1:525 ALEXANDRIA PIKE
Practice Address - Street 2:SUITE 200
Practice Address - City:SOUTHGATE
Practice Address - State:KY
Practice Address - Zip Code:41071-3290
Practice Address - Country:US
Practice Address - Phone:859-441-7913
Practice Address - Fax:859-441-4944
Is Sole Proprietor?:No
Enumeration Date:2010-02-23
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05009495A225100000X
KY005941225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100220980Medicaid
KYK041820Medicare PIN