Healthcare Provider Details

I. General information

NPI: 1073651154
Provider Name (Legal Business Name): JESSE WOISARD WENNIK NP, CNS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 11/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 BON AIR RD
GREENBRAE CA
94904-1702
US

IV. Provider business mailing address

250 BON AIR RD SUITE B
GREENBRAE CA
94904-1702
US

V. Phone/Fax

Practice location:
  • Phone: 415-499-6835
  • Fax: 415-507-4113
Mailing address:
  • Phone: 415-473-2964
  • Fax: 415-473-4113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number16967
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number16967
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: