Provider Demographics
NPI:1235418005
Name:WICKLINE, JESSICA (DO)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WICKLINE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 KYLE BEARD RD
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:WV
Mailing Address - Zip Code:24946-8524
Mailing Address - Country:US
Mailing Address - Phone:304-646-8427
Mailing Address - Fax:
Practice Address - Street 1:1709 HARPER RD
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3311
Practice Address - Country:US
Practice Address - Phone:304-256-3027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-11
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVED0221A207Q00000X
WV2634207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine