Provider Demographics
NPI:1306905054
Name:DEWILDE, JENNIFER RANEE (DC)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:RANEE
Last Name:DEWILDE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:RANEE
Other - Last Name:DEWILDE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:65 RAMAPO VALLEY RD STE 102B
Mailing Address - Street 2:
Mailing Address - City:MAHWAH
Mailing Address - State:NJ
Mailing Address - Zip Code:07430-1182
Mailing Address - Country:US
Mailing Address - Phone:732-300-0833
Mailing Address - Fax:
Practice Address - Street 1:65 RAMAPO VALLEY RD STE 102B
Practice Address - Street 2:
Practice Address - City:MAHWAH
Practice Address - State:NJ
Practice Address - Zip Code:07430-1182
Practice Address - Country:US
Practice Address - Phone:732-300-0833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOF09231068363LF0000X
IL038010352111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL671268OtherUNITED HEALTHCARE
IL038010352Medicaid
IL7932010OtherBCBS