| Doctor Name: | JACK LARRY WISDOM |
| NPI Number: | 1376968750 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | CSA |
| License Number: | 96534 |
| Business Practice Address: | 5974 Pentz Rd Paradise, CA - 959695509 |
| Business Phone Number: | 5308767903 |
| Business Fax Number: | |
| Mailing Address: | 261 Tranquil Dr, PARADISE |
| State: | CA |
| Postal Code: | 959693707 |
| Phone Number: | 5308768533 |
| Fax Number: | |
| NPI Enumeration Date: | 02/21/2014 |
| NPI Last Update Date: | 02/21/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 163W00000X |
| License Number: | 96534 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | TN |
| Taxonomy Type: | Nursing Service Providers |
| Taxonomy Classification: | Registered Nurse |
| Taxonomy Specialization: | |
| Taxonomy Definition: | (1) A registered nurse is a person qualified by graduation from an accredited nursing school (depending upon schooling, a registered nurse may receive either a diploma from a hospital program, an associate degree in nursing (A.D.N.) or a Bachelor of Science degree in nursing (B.S.N.), who is licensed or certified by the state, and is practicing within the scope of that license or certification. R.N. |