Provider Demographics
NPI:1962894311
Name:WOLESLAGLE, JENNA (PT)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:WOLESLAGLE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:
Other - Last Name:KUKLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:625 LINCOLN AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:CHARLEROI
Mailing Address - State:PA
Mailing Address - Zip Code:15022
Mailing Address - Country:US
Mailing Address - Phone:724-565-5806
Mailing Address - Fax:724-483-0290
Practice Address - Street 1:625 LINCOLN AVE STE 107
Practice Address - Street 2:
Practice Address - City:CHARLEROI
Practice Address - State:PA
Practice Address - Zip Code:15022
Practice Address - Country:US
Practice Address - Phone:724-565-5806
Practice Address - Fax:724-483-0290
Is Sole Proprietor?:No
Enumeration Date:2015-02-23
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT024214225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1030213100001Medicaid
PA1030213100001Medicaid