Provider Demographics
NPI:1841348844
Name:WOLF, JAMIE (PT)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:WOLF
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4215 NORTH 161ST AVE
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338
Mailing Address - Country:US
Mailing Address - Phone:602-717-0747
Mailing Address - Fax:623-242-6949
Practice Address - Street 1:2929 E FILLMORE ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-6159
Practice Address - Country:US
Practice Address - Phone:602-683-2400
Practice Address - Fax:602-275-8677
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2986174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ591554Medicaid