Provider Demographics
NPI:1336543297
Name:WILKENS, JENNA
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:WILKENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4085 BALL DIAMOND RD
Mailing Address - Street 2:
Mailing Address - City:HECTOR
Mailing Address - State:NY
Mailing Address - Zip Code:14841-9630
Mailing Address - Country:US
Mailing Address - Phone:607-215-6637
Mailing Address - Fax:
Practice Address - Street 1:220 STEUBEN ST
Practice Address - Street 2:
Practice Address - City:MONTOUR FALLS
Practice Address - State:NY
Practice Address - Zip Code:14865-9740
Practice Address - Country:US
Practice Address - Phone:607-535-7154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-21
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018028363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical