Provider Demographics
NPI:1962565127
Name:WILDEN, JESSICA ANNE (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANNE
Last Name:WILDEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2551 GREENWOOD RD STE 320
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3989
Mailing Address - Country:US
Mailing Address - Phone:318-212-8176
Mailing Address - Fax:318-212-8186
Practice Address - Street 1:2551 GREENWOOD RD STE 320
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3989
Practice Address - Country:US
Practice Address - Phone:182-127-1763
Practice Address - Fax:318-212-8186
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT186916207T00000X
LAMD.206396207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2342053Medicaid