Provider Demographics
NPI:1053085076
Name:WACKERMAN, JESSIE
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:WACKERMAN
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 1:4101 MOUNT CANTARA CIR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-7942
Mailing Address - Country:US
Mailing Address - Phone:714-267-9817
Mailing Address - Fax:
Practice Address - Street 1:4101 MOUNT CANTARA CIR
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-7942
Practice Address - Country:US
Practice Address - Phone:714-267-9817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95017895363LA2200X, 363LG0600X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology