MEDICARE: MRS. JEAN K WILSON

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	2251P0200X	Pediatric Physical Therapist	003426	FL

General Provider Information

NPI Number	:	1720161094
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JEAN K WILSON

Provider Business Mailing Address
First Line	:	9720 SW 162ND ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33157-3318
Country	:	US
Telephone Number	:	305-253-3391
Fax Number	:	305-251-7490

Provider Business Practice Location Address
First Line	:	9720 SW 162ND ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33157-3318
Country	:	US
Telephone Number	:	305-253-3391
Fax Number	:	305-251-7490

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

Provider Enumeration Date	:	10/23/2006
Last Update Date	:	07/08/2007

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