Provider Demographics
NPI:1003109844
Name:WILD, JERRICA MARIE
Entity Type:Individual
Prefix:MRS
First Name:JERRICA
Middle Name:MARIE
Last Name:WILD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15301 WARREN SHINGLE RD
Mailing Address - Street 2:
Mailing Address - City:BEALE AFB
Mailing Address - State:CA
Mailing Address - Zip Code:95903-1907
Mailing Address - Country:US
Mailing Address - Phone:530-634-4738
Mailing Address - Fax:
Practice Address - Street 1:15301 WARREN SHINGLE ROAD
Practice Address - Street 2:
Practice Address - City:BEALE AFB
Practice Address - State:CA
Practice Address - Zip Code:95903
Practice Address - Country:US
Practice Address - Phone:530-634-4738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-26
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians