Provider Demographics
NPI:1194296251
Name:WILDERMAN, JESSICA ANN
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:WILDERMAN
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 1:6765 BASS HWY
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34771-8565
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6928 BARBY LN
Practice Address - Street 2:
Practice Address - City:BELLE ISLE
Practice Address - State:FL
Practice Address - Zip Code:32812-3718
Practice Address - Country:US
Practice Address - Phone:863-447-3232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11000542363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily