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General NPI Number Information
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NPI Number | 1396867750
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Entity Type | Individual
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Provider Name | JENNIFER L WILD OTR
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Gender | Female
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Dates
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Enumeration Date | 04/05/2007
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Last Update Date | 01/22/2021
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Provider Practice Location Address
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Address Line | 1483 SW BOUGAINVILLEA AVE
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34953-7302
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Country | US
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Telephone | 772-336-6928
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Fax |
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Provider Business Mailing Address
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Address Line | 10702 SW ELSINORE DR
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34987-2149
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Country | US
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Telephone | 772-336-6928
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | OT8477
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License Number State | FL
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