Provider Demographics
NPI:1124868617
Name:WOLFE, JANSEN NICOLE (DPT)
Entity type:Individual
Prefix:
First Name:JANSEN
Middle Name:NICOLE
Last Name:WOLFE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 215
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:OH
Mailing Address - Zip Code:45771-0215
Mailing Address - Country:US
Mailing Address - Phone:740-612-2551
Mailing Address - Fax:
Practice Address - Street 1:1025 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:PAINTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41240-8645
Practice Address - Country:US
Practice Address - Phone:606-789-5808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV004736225100000X
KY009071225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist