Provider Demographics
NPI:1174725147
Name:WYLIE, JENNIFER SUE (PT)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:SUE
Last Name:WYLIE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:SUE
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:121 BYRON DR
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-0963
Mailing Address - Country:US
Mailing Address - Phone:270-898-2289
Mailing Address - Fax:
Practice Address - Street 1:121 BYRON DR
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-0963
Practice Address - Country:US
Practice Address - Phone:270-898-2289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY000999225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0637303Medicare PIN