Provider Demographics
NPI:1639732167
Name:WILDER, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WILDER
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:BRANCH HEALTH CLINIC OCEANA
Mailing Address - Street 2:1750 TOMCAT BLVD
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23460
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:NAVAL MEDICAL CENTER SAN DIEGO 38400 BOB WILSON DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-5000
Practice Address - Country:US
Practice Address - Phone:907-830-4016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-19
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000000OtherMILITARY