MEDICARE: JESSICA WISEMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376J00000X	Homemaker

General Provider Information

NPI Number	:	1619822103
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA WISEMAN

Provider Business Mailing Address
First Line	:	2217 KAY NEVA LN
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25312-9420
Country	:	US
Telephone Number	:	304-898-4109
Fax Number	:

Provider Business Practice Location Address
First Line	:	4510 PENNSYLVANIA AVE STE C
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25302-4835
Country	:	US
Telephone Number	:	304-965-9081
Fax Number	:	304-471-2488

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/02/2026
Last Update Date	:	03/02/2026

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Directions to “ JESSICA WISEMAN ” Practice Location

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