MEDICARE: JENNIFER L WICHTERMAN PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	7865	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558541391
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER L WICHTERMAN PT

Provider Business Mailing Address
First Line	:	1001 KAMOKILA BLVD
Second Line	:	SUITE 114
City	:	KAPOLEI
State	:	HI
Zip	:	96707-2097
Country	:	US
Telephone Number	:	808-674-0500
Fax Number	:	808-674-0511

Provider Business Practice Location Address
First Line	:	99-128 AIEA HEIGHTS DRIVE
Second Line	:	SUITE 114
City	:	AIEA
State	:	HI
Zip	:	96701-3968
Country	:	US
Telephone Number	:	808-487-0487
Fax Number	:	808-486-8674

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2007
Last Update Date	:	07/18/2015

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