Provider Demographics
NPI:1194074351
Name:WICK, JENNIFER LEIGH (MT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEIGH
Last Name:WICK
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 TABLE MESA DR STE 203
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80305-5850
Mailing Address - Country:US
Mailing Address - Phone:303-499-9892
Mailing Address - Fax:
Practice Address - Street 1:3400 TABLE MESA DR STE 203
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-5850
Practice Address - Country:US
Practice Address - Phone:303-499-9892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-04
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0013860225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist