=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255326252
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER RENEE WISE MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2005
-----------------------------------------------------
Last Update Date | 02/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2821 DAGGETT AVE STE 200
-----------------------------------------------------
City | KLAMATH FALLS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97601-1106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-274-8400
-----------------------------------------------------
Fax | 541-274-8405
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2865 DAGGETT AVE
-----------------------------------------------------
City | KLAMATH FALLS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97601-1106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-274-8400
-----------------------------------------------------
Fax | 541-274-8405
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 12016
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | MD192270
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------