Healthcare Provider Details

I. General information

NPI: 1760972491
Provider Name (Legal Business Name): JILLIAN ALEXANDRA WESSELMAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS JILLIAN ALEXANDRA GOODWIN

II. Dates (important events)

Enumeration Date: 05/17/2018
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 SAMARITAN DR
SAN JOSE CA
95124
US

IV. Provider business mailing address

18085 IDALYN DR
LOS GATOS CA
95033-8924
US

V. Phone/Fax

Practice location:
  • Phone: 408-559-2011
  • Fax:
Mailing address:
  • Phone: 408-204-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95059691
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95009247
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: