Healthcare Provider Details

I. General information

NPI: 1053227470
Provider Name (Legal Business Name): JERI JEAN WILDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4782 SIENNA DR
SAINT JOSEPH MO
64506-4862
US

IV. Provider business mailing address

4782 SIENNA DR
SAINT JOSEPH MO
64506-4862
US

V. Phone/Fax

Practice location:
  • Phone: 800-952-8387
  • Fax: 913-785-6817
Mailing address:
  • Phone: 800-952-8387
  • Fax: 913-785-6817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: