=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891437216
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER MARIE WICKENS MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2022
-----------------------------------------------------
Last Update Date | 06/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 E COLUMBIA AVE
-----------------------------------------------------
City | COLVILLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99114-3354
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-684-3701
-----------------------------------------------------
Fax | 509-684-5817
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | POB 31001-4114
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91110-4114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-747-2455
-----------------------------------------------------
Fax | 509-944-9644
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | ML61481130
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------