Provider Demographics
NPI:1790232130
Name:WOLF, JAMESON WALKER
Entity Type:Individual
Prefix:
First Name:JAMESON
Middle Name:WALKER
Last Name:WOLF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 PARK WAY
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94611-3941
Mailing Address - Country:US
Mailing Address - Phone:510-332-1989
Mailing Address - Fax:
Practice Address - Street 1:225 37TH AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-4324
Practice Address - Country:US
Practice Address - Phone:650-573-2541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program