Provider Demographics
NPI:1588544506
Name:WIKE, JENNA R
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:R
Last Name:WIKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 VICTORIA PARK DR
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-5440
Mailing Address - Country:US
Mailing Address - Phone:315-456-9049
Mailing Address - Fax:
Practice Address - Street 1:750 E ADAMS ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1834
Practice Address - Country:US
Practice Address - Phone:315-456-9049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-03
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054657225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist