Provider Demographics
NPI:1184744450
Name:WILDMAN, JANE B
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:B
Last Name:WILDMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:B
Other - Last Name:WILDMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:VA
Mailing Address - Street 1:PO BOX 1992
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:CO
Mailing Address - Zip Code:81623-4992
Mailing Address - Country:US
Mailing Address - Phone:970-319-0116
Mailing Address - Fax:
Practice Address - Street 1:1330 PITKIN AVE
Practice Address - Street 2:
Practice Address - City:GLENWOOD SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81601-4295
Practice Address - Country:US
Practice Address - Phone:970-319-0116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0000000235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist