Provider Demographics
NPI:1336238419
Name:WIGTON, JENNIFER LYNN (PHD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:WIGTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5352 12TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-1837
Mailing Address - Country:US
Mailing Address - Phone:612-723-0460
Mailing Address - Fax:952-928-9774
Practice Address - Street 1:4500 PARK GLEN RD
Practice Address - Street 2:SUITE 151
Practice Address - City:SAINT LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-4871
Practice Address - Country:US
Practice Address - Phone:612-723-0460
Practice Address - Fax:952-928-9774
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4489103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist