Provider Demographics
NPI:1255326252
Name:WISE, JENNIFER RENEE (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RENEE
Last Name:WISE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2865 DAGGETT AVE
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-1106
Mailing Address - Country:US
Mailing Address - Phone:541-274-8400
Mailing Address - Fax:541-274-8405
Practice Address - Street 1:2821 DAGGETT AVE STE 200
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1106
Practice Address - Country:US
Practice Address - Phone:541-274-8400
Practice Address - Fax:541-274-8405
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH12016207R00000X
ORMD192270207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHP00179641OtherRR MEDICARE PIN
NH3369774OtherAETNA PROV #
NH30203784Medicaid
NH6000361OtherHPHC PIN
NH101115805OtherDOL W/C PIN
NH30367YOtherRAN PIN
NH5796012OtherCIGNA PIN
NH012016OtherTUFTS PIN
NH01YP05180NH01OtherANTHEM ACES PIN