Provider Demographics
NPI:1477682235
Name:WICKERSHAM, JILL JANAE (MS IN MARRIAGE AND F)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:JANAE
Last Name:WICKERSHAM
Suffix:
Gender:F
Credentials:MS IN MARRIAGE AND F
Other - Prefix:MS
Other - First Name:JILL
Other - Middle Name:JANAE
Other - Last Name:MCCANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS IN MARRIAGE AND F
Mailing Address - Street 1:1885 LUNDY AVENUE
Mailing Address - Street 2:SUITE 223
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95131
Mailing Address - Country:US
Mailing Address - Phone:408-284-9000
Mailing Address - Fax:408-284-9048
Practice Address - Street 1:1600 W CAMPBELL AVE STE 201
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-1526
Practice Address - Country:US
Practice Address - Phone:408-871-4908
Practice Address - Fax:408-871-4903
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2019-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44905106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist