Provider Demographics
NPI:1578816633
Name:WRIGHT, JENNIFER NICHOLE (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NICHOLE
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:NICHOLE
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:10775 N MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93730-3565
Mailing Address - Country:US
Mailing Address - Phone:559-260-2762
Mailing Address - Fax:
Practice Address - Street 1:10775 NORTH MAPLE AVENUE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93730-3619
Practice Address - Country:US
Practice Address - Phone:559-260-2762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-25
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22468363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant