Provider Demographics
NPI:1649685066
Name:WILSON, JENNA LYNNE
Entity type:Individual
Prefix:MS
First Name:JENNA
Middle Name:LYNNE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JENNA
Other - Middle Name:LYNNE
Other - Last Name:HUMPHREYS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2958 STATE STREET
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2958 STATE STREET
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93105
Practice Address - Country:US
Practice Address - Phone:805-705-5571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-24
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACALM 392176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife