Healthcare Provider Details

I. General information

NPI: 1093751414
Provider Name (Legal Business Name): JENNIFER WICKARD MSPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 BIG SPRING RD
NEWVILLE PA
17241-9497
US

IV. Provider business mailing address

599 MOHAWK RD
NEWVILLE PA
17241-9016
US

V. Phone/Fax

Practice location:
  • Phone: 717-776-8255
  • Fax: 717-776-6266
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT012170L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: