Basic Information
| Provider Information | |||||||||
| NPI: | 1538579271 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WICKERSHAM | ||||||||
| FirstName: | JENNA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MAC LN | ||||||||
| Address2: | |||||||||
| City: | PIERRE | ||||||||
| State: | SD | ||||||||
| PostalCode: | 575013391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6052245901 | ||||||||
| FaxNumber: | 6059455083 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 MAC LN | ||||||||
| Address2: | |||||||||
| City: | PIERRE | ||||||||
| State: | SD | ||||||||
| PostalCode: | 575013391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6052245901 | ||||||||
| FaxNumber: | 6059455083 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2014 | ||||||||
| LastUpdateDate: | 07/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0085 | SD | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 10716 | SD | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.