Provider Demographics
NPI:1174012041
Name:WISE, JESSIE G (CRM)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:G
Last Name:WISE
Suffix:
Gender:M
Credentials:CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 I AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-2043
Mailing Address - Country:US
Mailing Address - Phone:541-962-0162
Mailing Address - Fax:541-962-0119
Practice Address - Street 1:1501 6TH ST
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-2419
Practice Address - Country:US
Practice Address - Phone:541-962-0162
Practice Address - Fax:541-962-0162
Is Sole Proprietor?:No
Enumeration Date:2018-05-07
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18-CRM-092175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist