Provider Demographics
NPI:1316925035
Name:GELLER, JEAN WADHAMS (NP)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:WADHAMS
Last Name:GELLER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3812 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-4301
Mailing Address - Country:US
Mailing Address - Phone:559-495-3120
Mailing Address - Fax:559-495-3134
Practice Address - Street 1:3152 N MILLBROOK AVE
Practice Address - Street 2:SUITE B
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-1459
Practice Address - Country:US
Practice Address - Phone:559-244-0133
Practice Address - Fax:559-244-0148
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA275340163WW0101X
CA5681363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA275340OtherREGISTERED NURSE
CA5681OtherNURSE PRACTITIONER LIC