Provider Demographics
NPI:1750994661
Name:WILDE, JILLANA (LMT)
Entity type:Individual
Prefix:
First Name:JILLANA
Middle Name:
Last Name:WILDE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14079 W 30TH LN
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80401-1568
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12001 W 63RD PL STE 5
Practice Address - Street 2:
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80004-4032
Practice Address - Country:US
Practice Address - Phone:303-332-5136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-29
Last Update Date:2020-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0022305225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist