Healthcare Provider Details

I. General information

NPI: 1871165118
Provider Name (Legal Business Name): JENNIFER WICKLUND FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2021
Last Update Date: 02/22/2024
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4664 N PENNGROVE WAY STE 100
MERIDIAN ID
83646-7442
US

IV. Provider business mailing address

4664 N PENNGROVE WAY STE 100
MERIDIAN ID
83646-7442
US

V. Phone/Fax

Practice location:
  • Phone: 208-898-7467
  • Fax: 208-398-2120
Mailing address:
  • Phone: 208-898-7467
  • Fax: 208-398-2120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704278431
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: