Provider Demographics
NPI:1396382396
Name:WISE, JACQUELEEN (CRNP)
Entity Type:Individual
Prefix:
First Name:JACQUELEEN
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 BURGESS RD
Mailing Address - Street 2:
Mailing Address - City:COLLEGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19426-1784
Mailing Address - Country:US
Mailing Address - Phone:215-694-2780
Mailing Address - Fax:
Practice Address - Street 1:3401 CIVIC CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4319
Practice Address - Country:US
Practice Address - Phone:215-590-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP021229363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics