Provider Demographics
NPI:1144457664
Name:WISDOM, JENNIFER DEGEYTER (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:DEGEYTER
Last Name:WISDOM
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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Mailing Address - Street 1:4752 BRIDGE STREET HWY
Mailing Address - Street 2:
Mailing Address - City:ST. MARTINVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70582
Mailing Address - Country:US
Mailing Address - Phone:337-845-4880
Mailing Address - Fax:
Practice Address - Street 1:210 CHAMPAGNE BLVD
Practice Address - Street 2:
Practice Address - City:BREAUX BRIDGE
Practice Address - State:LA
Practice Address - Zip Code:70517-3700
Practice Address - Country:US
Practice Address - Phone:337-507-1106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-11
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAZ20509224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant