Healthcare Provider Details

I. General information

NPI: 1609828474
Provider Name (Legal Business Name): KENDRA JAYNE WILKS MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KENDRA SHAPPEE

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 01/23/2023
Certification Date: 01/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S 21ST ST UNIT 130
COLORADO SPRINGS CO
80904-3763
US

IV. Provider business mailing address

600 S 21ST ST UNIT 130
COLORADO SPRINGS CO
80904-3763
US

V. Phone/Fax

Practice location:
  • Phone: 719-634-1110
  • Fax: 719-634-1112
Mailing address:
  • Phone: 719-634-1110
  • Fax: 719-634-1112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number62838
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT60131985
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: