Provider Demographics
NPI:1306020961
Name:WICK, JANNIFER LYNN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JANNIFER
Middle Name:LYNN
Last Name:WICK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 JOHN PAUL JONES CIR
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23708-2111
Mailing Address - Country:US
Mailing Address - Phone:757-953-5000
Mailing Address - Fax:
Practice Address - Street 1:1600 SEABEE DRIVE
Practice Address - Street 2:NSWG EIGHT MED DEPT
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23459
Practice Address - Country:US
Practice Address - Phone:757-763-2508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-19
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1080526363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant