Provider Demographics
NPI:1316321391
Name:WILSON, JOVENE IDANA (OTR-L)
Entity type:Individual
Prefix:MRS
First Name:JOVENE
Middle Name:IDANA
Last Name:WILSON
Suffix:
Gender:F
Credentials:OTR-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 HENDRICKSON PASS
Mailing Address - Street 2:
Mailing Address - City:HARLAN
Mailing Address - State:KY
Mailing Address - Zip Code:40831-7117
Mailing Address - Country:US
Mailing Address - Phone:606-574-9245
Mailing Address - Fax:
Practice Address - Street 1:41 HENDRICKSON PASS
Practice Address - Street 2:
Practice Address - City:HARLAN
Practice Address - State:KY
Practice Address - Zip Code:40831-7117
Practice Address - Country:US
Practice Address - Phone:606-574-9245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-19
Last Update Date:2015-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-R1893225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist