Healthcare Provider Details

I. General information

NPI: 1275665200
Provider Name (Legal Business Name): JACQUELINE WISH FNP MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 10/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2950 INTERNATIONAL BLVD NATIVE AMERICAN HEALTH CENTER
OAKLAND CA
94601-2228
US

IV. Provider business mailing address

2950 INTERNATIONAL BLVD NATIVE AMERICAN HEALTH CENTER
OAKLAND CA
94601-2228
US

V. Phone/Fax

Practice location:
  • Phone: 510-535-4400
  • Fax:
Mailing address:
  • Phone: 510-535-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN272107
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberNPF4281
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: