Healthcare Provider Details

I. General information

NPI: 1235412412
Provider Name (Legal Business Name): JENNIFER L. WILDE DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2011
Last Update Date: 07/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 8TH AVE NE SUITE 340
ISSAQUAH WA
98029-5436
US

IV. Provider business mailing address

805 MADISON ST SUITE 901
SEATTLE WA
98104-1172
US

V. Phone/Fax

Practice location:
  • Phone: 425-313-3055
  • Fax: 425-313-3051
Mailing address:
  • Phone: 206-264-8100
  • Fax: 206-264-8689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT60293716
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: