Healthcare Provider Details

I. General information

NPI: 1588953582
Provider Name (Legal Business Name): JENNIFER MARIE WILD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2011
Last Update Date: 04/29/2021
Certification Date: 04/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12800 BOTHELL EVERETT HWY
EVERETT WA
98208-6642
US

IV. Provider business mailing address

PO BOX 3360
PORTLAND OR
97208-3360
US

V. Phone/Fax

Practice location:
  • Phone: 425-316-5188
  • Fax: 425-225-1005
Mailing address:
  • Phone: 866-366-2983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD 60455588
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: