Healthcare Provider Details

I. General information

NPI: 1790205292
Provider Name (Legal Business Name): JESSICA LYNN WISDOM FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2017
Last Update Date: 06/09/2021
Certification Date: 05/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 DICKINSON RD
CHESTERTON IN
46304-3387
US

IV. Provider business mailing address

2022 KELLE DR
CHESTERTON IN
46304-8708
US

V. Phone/Fax

Practice location:
  • Phone: 219-926-7755
  • Fax: 219-929-1885
Mailing address:
  • Phone: 219-364-3616
  • Fax: 219-364-3610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28187239A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71007325A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: