Provider Demographics
NPI:1982780342
Name:WILEY, JENNIFER JOAN (MPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JOAN
Last Name:WILEY
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3744 S TIMBERLINE RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-4333
Mailing Address - Country:US
Mailing Address - Phone:970-204-4263
Mailing Address - Fax:
Practice Address - Street 1:3744 S TIMBERLINE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-4333
Practice Address - Country:US
Practice Address - Phone:970-204-4263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-28
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5202225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO71489738Medicaid
CO71489738Medicaid