Provider Demographics
NPI:1689835761
Name:WICKER, JENELLE CHRISTINE (LMP)
Entity Type:Individual
Prefix:MISS
First Name:JENELLE
Middle Name:CHRISTINE
Last Name:WICKER
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 116TH AVE NE STE 106
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3034
Mailing Address - Country:US
Mailing Address - Phone:425-467-5955
Mailing Address - Fax:425-467-5839
Practice Address - Street 1:1605 116TH AVE NE STE 106
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3034
Practice Address - Country:US
Practice Address - Phone:425-467-5955
Practice Address - Fax:425-467-5839
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-20
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA0023791174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist