Provider Demographics
NPI:1659743458
Name:WILSON, JENNIFER MICHELLE (PT, DPT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9126 SW RIDDER RD
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-6766
Mailing Address - Country:US
Mailing Address - Phone:503-308-4060
Mailing Address - Fax:
Practice Address - Street 1:9126 SW RIDDER RD
Practice Address - Street 2:
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-6766
Practice Address - Country:US
Practice Address - Phone:503-308-4060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-20
Last Update Date:2025-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3831225100000X
CA43048225100000X
OR65267225100000X
WA60539796225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA179796Medicare PIN