Provider Demographics
NPI:1780857383
Name:WONG, JENNIFER R (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:WONG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:40 RICHARDS DR
Mailing Address - Street 2:
Mailing Address - City:FORT MADISON
Mailing Address - State:IA
Mailing Address - Zip Code:52627-2138
Mailing Address - Country:US
Mailing Address - Phone:419-447-7203
Mailing Address - Fax:419-447-5577
Practice Address - Street 1:1600 MORGAN ST
Practice Address - Street 2:
Practice Address - City:KEOKUK
Practice Address - State:IA
Practice Address - Zip Code:52632-3456
Practice Address - Country:US
Practice Address - Phone:419-447-7203
Practice Address - Fax:419-447-5577
Is Sole Proprietor?:No
Enumeration Date:2008-04-04
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA004145225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist