Provider Demographics
NPI:1376653915
Name:WHEELER, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WHEELER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21669 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48183-1338
Mailing Address - Country:US
Mailing Address - Phone:734-307-0911
Mailing Address - Fax:
Practice Address - Street 1:21669 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:BROWNSTOWN TWP
Practice Address - State:MI
Practice Address - Zip Code:48183-1338
Practice Address - Country:US
Practice Address - Phone:734-307-0911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225200000X
MI5501015382225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIPTAOtherLICENSE #