Healthcare Provider Details

I. General information

NPI: 1174942064
Provider Name (Legal Business Name): JENNA KAYE WILDMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2014
Last Update Date: 07/13/2020
Certification Date: 07/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2095 HENRY TECKLENBURG DR
CHARLESTON SC
29414-5733
US

IV. Provider business mailing address

PO BOX 751649
CHARLOTTE NC
28275-1649
US

V. Phone/Fax

Practice location:
  • Phone: 843-789-1892
  • Fax: 843-606-8036
Mailing address:
  • Phone: 251-415-8602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number81716
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: