Provider Demographics
NPI:1376968750
Name:WISDOM, JACK LARRY (CSA)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:LARRY
Last Name:WISDOM
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 TRANQUIL DR
Mailing Address - Street 2:
Mailing Address - City:PARADISE
Mailing Address - State:CA
Mailing Address - Zip Code:95969-3707
Mailing Address - Country:US
Mailing Address - Phone:530-876-8533
Mailing Address - Fax:
Practice Address - Street 1:5974 PENTZ RD
Practice Address - Street 2:
Practice Address - City:PARADISE
Practice Address - State:CA
Practice Address - Zip Code:95969-5509
Practice Address - Country:US
Practice Address - Phone:530-876-7903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-21
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA718316163W00000X
TN96534163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse