Provider Demographics
NPI:1073511481
Name:WICKS, JENNIFER L (APRN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:WICKS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:ENSCOE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 TAMPA GENERAL CIR
Practice Address - Street 2:STC 5TH FLOOR
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3603
Practice Address - Country:US
Practice Address - Phone:813-259-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-09
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9343457363L00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019798900Medicaid
FL5YDQPOtherBLUE CROSS BLUE SHIELD
P15065Medicare UPIN