Provider Demographics
NPI:1336731744
Name:WIGGERS, JOHN CONNOR
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CONNOR
Last Name:WIGGERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 INTERNATIONAL PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5028
Mailing Address - Country:US
Mailing Address - Phone:855-610-0580
Mailing Address - Fax:
Practice Address - Street 1:139 E OLD TRENTON RD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-5857
Practice Address - Country:US
Practice Address - Phone:407-915-7258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-07
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician