Provider Demographics
NPI:1710970355
Name:WILDER, JENNIFER S (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:S
Last Name:WILDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:SLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 791128
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-1128
Mailing Address - Country:US
Mailing Address - Phone:703-726-0003
Mailing Address - Fax:703-726-6444
Practice Address - Street 1:20905 PROFESSIONAL PLZ
Practice Address - Street 2:STE 330
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-7783
Practice Address - Country:US
Practice Address - Phone:703-726-0003
Practice Address - Fax:703-726-6444
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101231146207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA05647118Medicaid
P00009757OtherRR MEDICARE
VA002955F07Medicare PIN
VA05647118Medicaid
DC009018F32Medicare PIN