Provider Demographics
NPI:1760972491
Name:WESSELMAN, JILLIAN ALEXANDRA (NP)
Entity Type:Individual
Prefix:MRS
First Name:JILLIAN
Middle Name:ALEXANDRA
Last Name:WESSELMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:JILLIAN
Other - Middle Name:ALEXANDRA
Other - Last Name:GOODWIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18085 IDALYN DR
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95033-8924
Mailing Address - Country:US
Mailing Address - Phone:408-204-0400
Mailing Address - Fax:
Practice Address - Street 1:2425 SAMARITAN DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124
Practice Address - Country:US
Practice Address - Phone:408-559-2011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-17
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95059691163W00000X
CA95009247363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse