Provider Demographics
NPI:1891840484
Name:WILSON, JODI L (SLP)
Entity Type:Individual
Prefix:MS
First Name:JODI
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67202-4304
Mailing Address - Country:US
Mailing Address - Phone:316-267-5437
Mailing Address - Fax:316-267-5444
Practice Address - Street 1:340 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67202-4304
Practice Address - Country:US
Practice Address - Phone:316-267-5437
Practice Address - Fax:316-267-5444
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2553235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist