Provider Demographics
NPI:1285771451
Name:WIEGAND, JENNIFER S (LMP)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:S
Last Name:WIEGAND
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19063 12TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-7334
Mailing Address - Country:US
Mailing Address - Phone:360-779-7956
Mailing Address - Fax:360-697-1319
Practice Address - Street 1:19063 12TH AVE NE
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-7334
Practice Address - Country:US
Practice Address - Phone:360-779-7956
Practice Address - Fax:360-697-1319
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMAOOO20316174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMAOOO20316OtherLMP LICENSE #