Healthcare Provider Details

I. General information

NPI: 1225377187
Provider Name (Legal Business Name): JENNIFER ANN WILSON P.T., D.P.T
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2013
Last Update Date: 08/20/2021
Certification Date: 08/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1958 VIA CTR
VISTA CA
92081-6056
US

IV. Provider business mailing address

3905 WARING RD
OCEANSIDE CA
92056-4405
US

V. Phone/Fax

Practice location:
  • Phone: 760-477-1350
  • Fax: 760-754-6785
Mailing address:
  • Phone: 760-724-9000
  • Fax: 760-724-3686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number38634
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: