Healthcare Provider Details

I. General information

NPI: 1407214430
Provider Name (Legal Business Name): JILLIAN C. WIEDA MSC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2016
Last Update Date: 10/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 N 1ST ST
FRESNO CA
93726-2304
US

IV. Provider business mailing address

10237 N BOYD AVE
FRESNO CA
93730-4512
US

V. Phone/Fax

Practice location:
  • Phone: 559-225-1102
  • Fax: 559-375-7164
Mailing address:
  • Phone: 559-930-5462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: