MEDICARE: DR. JENNIFER LYNN WIGTON PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	LP4489	MN

General Provider Information

NPI Number	:	1336238419
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER LYNN WIGTON PH.D.

Provider Business Mailing Address
First Line	:	5352 12TH AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55417-1837
Country	:	US
Telephone Number	:	612-723-0460
Fax Number	:	952-928-9774

Provider Business Practice Location Address
First Line	:	4500 PARK GLEN RD
Second Line	:	SUITE 151
City	:	SAINT LOUIS PARK
State	:	MN
Zip	:	55416-4871
Country	:	US
Telephone Number	:	612-723-0460
Fax Number	:	952-928-9774

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	07/08/2007

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