Provider Demographics
NPI:1811098387
Name:WILSON, JENNIFER A (PT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:A
Other - Last Name:MESSMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7191 S KINGERY HWY
Practice Address - Street 2:SUITE L6
Practice Address - City:WILLOWBROOK
Practice Address - State:IL
Practice Address - Zip Code:60527-5525
Practice Address - Country:US
Practice Address - Phone:630-455-6630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05013120A225100000X
IL070013922225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00844088OtherMEDICARE RR
ILK50778Medicare PIN
ILK22896Medicare PIN
ILP00352124Medicare PIN
ILP00844088OtherMEDICARE RR
ILK09694Medicare PIN