Basic Information
| Provider Information | |||||||||
| NPI: | 1760972491 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WESSELMAN | ||||||||
| FirstName: | JILLIAN | ||||||||
| MiddleName: | ALEXANDRA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GOODWIN | ||||||||
| OtherFirstName: | JILLIAN | ||||||||
| OtherMiddleName: | ALEXANDRA | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 18085 IDALYN DR | ||||||||
| Address2: | |||||||||
| City: | LOS GATOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950338924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082040400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2425 SAMARITAN DR | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4085592011 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2018 | ||||||||
| LastUpdateDate: | 06/21/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 95059691 | CA | N | Nursing Service Providers | Registered Nurse | 363L00000X | 95009247 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.