Provider Demographics
NPI:1760899686
Name:WICKLINE, JEFFREY W (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:W
Last Name:WICKLINE
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1222 MATTEO DRIVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-1000
Mailing Address - Country:US
Mailing Address - Phone:203-217-9366
Mailing Address - Fax:
Practice Address - Street 1:3260 OCEANIC BAY DR
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-6401
Practice Address - Country:US
Practice Address - Phone:203-217-9366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-14
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001758225X00000X
NC9721225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist