MEDICARE: MRS. JAMIE WICK MS

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	171M00000X	Case Manager/Care Coordinator		WA

General Provider Information

NPI Number	:	1942854179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JAMIE WICK MS

Provider Business Mailing Address
First Line	:	1338 COMMERCE AVE STE 212
Second Line	:
City	:	LONGVIEW
State	:	WA
Zip	:	98632-3726
Country	:	US
Telephone Number	:	360-986-3591
Fax Number	:	360-768-5547

Provider Business Practice Location Address
First Line	:	1338 COMMERCE AVE STE 212
Second Line	:
City	:	LONGVIEW
State	:	WA
Zip	:	98632-3726
Country	:	US
Telephone Number	:	360-986-3591
Fax Number	:	360-768-5547

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

Provider Enumeration Date	:	07/25/2019
Last Update Date	:	07/25/2019

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