Healthcare Provider Details

I. General information

NPI: 1083072417
Provider Name (Legal Business Name): JENNIFER WYLDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2016
Last Update Date: 01/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27071 ALISO CREEK RD
ALISO VIEJO CA
92656-5327
US

IV. Provider business mailing address

27071 ALISO CREEK RD
ALISO VIEJO CA
92656-5327
US

V. Phone/Fax

Practice location:
  • Phone: 888-468-4372
  • Fax:
Mailing address:
  • Phone: 888-468-4372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number7918
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: