Provider Demographics
NPI:1841508017
Name:WIRT, JENNIFER N (PT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:N
Last Name:WIRT
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 1:860 VIA DE LA PAZ
Mailing Address - Street 2:SUITE B1
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272
Mailing Address - Country:US
Mailing Address - Phone:310-573-9553
Mailing Address - Fax:310-573-9533
Practice Address - Street 1:860 VIA DE LA PAZ
Practice Address - Street 2:SUITE B1
Practice Address - City:PACIFIC PALISADES
Practice Address - State:CA
Practice Address - Zip Code:90272
Practice Address - Country:US
Practice Address - Phone:310-573-9553
Practice Address - Fax:310-573-9533
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4362225100000X
CA292214225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist