1477682235 NPI number — MRS. JILL JANAE WICKERSHAM MS IN MARRIAGE AND F

Table of content: MRS. JILL JANAE WICKERSHAM MS IN MARRIAGE AND F (NPI 1477682235)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477682235 NPI number — MRS. JILL JANAE WICKERSHAM MS IN MARRIAGE AND F

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WICKERSHAM
Provider First Name:
JILL
Provider Middle Name:
JANAE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS IN MARRIAGE AND F
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCCANN
Provider Other First Name:
JILL
Provider Other Middle Name:
JANAE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS IN MARRIAGE AND F
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1477682235
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1885 LUNDY AVENUE
Provider Second Line Business Mailing Address:
SUITE 223
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95131
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-284-9000
Provider Business Mailing Address Fax Number:
408-284-9048

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 W CAMPBELL AVE STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMPBELL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95008-1526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-871-4908
Provider Business Practice Location Address Fax Number:
408-871-4903
Provider Enumeration Date:
03/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  44905 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com