Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0019X | Occupational Therapist - Physical Rehabilitation | 31007111A | IN |
NPI | 1326659319 |
---|---|
Provider Name | Jessica Wildman |
First Address | Columbia City, IN 46725-8780 |
Second Address | Columbia City, IN 46725-8780 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/08/2020 |
Last Update Date | 12/08/2020 |