Basic Information
| Provider Information | |||||||||
| NPI: | 1760704431 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILBURN | ||||||||
| FirstName: | JARED | ||||||||
| MiddleName: | COLE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 560 S LOOP RD | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593012663 | ||||||||
| FaxNumber: | 8593010655 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 ALEXANDRIA PIKE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SOUTHGATE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410713290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594417913 | ||||||||
| FaxNumber: | 8594414944 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2010 | ||||||||
| LastUpdateDate: | 05/12/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 05009495A | IN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 005941 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 7100220980 | 05 | KY | MEDICAID |