Provider Demographics
NPI:1376602060
Name:WICKHAM, JESSE M (DO)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:M
Last Name:WICKHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:3551 ROGER BROOKE DR
Mailing Address - Street 2:
Mailing Address - City:JBSA FT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:210-916-7408
Mailing Address - Fax:210-916-3585
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:JBSA FT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-916-7408
Practice Address - Fax:210-916-3585
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2018-03-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN02003331A207RN0300X
MS23573207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology