Provider Demographics
NPI:1780872226
Name:WILSON, JENNIFER ANN (MPT)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22898 180TH STREET
Mailing Address - Street 2:
Mailing Address - City:PURCELL
Mailing Address - State:OK
Mailing Address - Zip Code:73080-4316
Mailing Address - Country:US
Mailing Address - Phone:405-473-6861
Mailing Address - Fax:
Practice Address - Street 1:131 S FLOOD AVE
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-5463
Practice Address - Country:US
Practice Address - Phone:405-321-1220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-10
Last Update Date:2025-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36783225100000X
OKPT 4017225100000X
OK4017225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOK400113Medicare PIN