Provider Demographics
NPI:1184672628
Name:WILDEMAN, JACKI L (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:JACKI
Middle Name:L
Last Name:WILDEMAN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4015 GATEWAY BLVD STE 2120
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-9460
Mailing Address - Country:US
Mailing Address - Phone:812-842-0907
Mailing Address - Fax:812-464-4485
Practice Address - Street 1:4007 GATEWAY BLVD # 100
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-8947
Practice Address - Country:US
Practice Address - Phone:812-842-0907
Practice Address - Fax:812-490-7054
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001467A363L00000X, 363LA2100X
KY3899P363LA2100X
IL309002150363LA2100X
IN28079891A363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78009586Medicaid
000000270530OtherANTHEM
IN200427140Medicaid
P77136Medicare UPIN
IN532500WWMedicare PIN
KY0255535Medicare PIN