Provider Demographics
NPI:1932414182
Name:WING, JENNA L (DPT)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:L
Last Name:WING
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:L
Other - Last Name:DAUPHINEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:840 HAMMOND ST
Mailing Address - Street 2:# 2
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-4339
Mailing Address - Country:US
Mailing Address - Phone:207-433-7778
Mailing Address - Fax:866-220-5031
Practice Address - Street 1:840 HAMMOND ST STE 2
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4339
Practice Address - Country:US
Practice Address - Phone:207-433-7778
Practice Address - Fax:866-220-5031
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-12
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT3687225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1932414182OtherANTHEM
MEP00871623OtherRR MEDICARE
ME1932414182OtherANTHEM