Healthcare Provider Details

I. General information

NPI: 1558190751
Provider Name (Legal Business Name): JAZMIN WISE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 07/29/2024
Certification Date: 07/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 W MACARTHUR BLVD
OAKLAND CA
94611-5641
US

IV. Provider business mailing address

484 LAKE PARK AVE # 115
OAKLAND CA
94610-2730
US

V. Phone/Fax

Practice location:
  • Phone: 510-752-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number95020648
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: