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General NPI Number Information
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NPI Number | 1831697895
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Entity Type | Individual
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Provider Name | MRS. JESSIKA ROSE WILDENBERG
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Gender | Female
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Dates
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Enumeration Date | 01/24/2018
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Last Update Date | 01/24/2018
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Provider Practice Location Address
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Address Line | 1207 S JACKSON ST
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City | GREEN BAY
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State | WI
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Zip | 54301-3037
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Country | US
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Telephone | 920-593-7000
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Fax |
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Provider Business Mailing Address
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Address Line | N5392 COUNTY ROAD EE
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City | SEYMOUR
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State | WI
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Zip | 54165-8364
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Country | US
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Telephone | 920-419-6992
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | 4070050296
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License Number State | WI
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