Provider Information for 1366054660
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JENNIFER A WISS
Sex: Female
NPI: 1366054660
Last Updated: 2020-08-18
Certification Date: 2020-08-18
Certification Date: 2020-08-18
Details
| Name | Value | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| NPI | 1366054660 | ||||||||
| Enumeration Date | 2020-08-18 | ||||||||
| NPI Type | NPI-1 Individual | ||||||||
| Sole Proprietor | YES | ||||||||
| Status | Active | ||||||||
| Mailing Address | 16517 NE 79TH ST VANCOUVER, WA 98682-1522 United States Phone: 602-405-8285 | Fax: | ||||||||
| Primary Practice Address | 16517 NE 79TH ST VANCOUVER, WA 98682-1522 United States Phone: 602-405-8285 | Fax: | ||||||||
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