Provider Demographics
NPI:1316650393
Name:WIESINGER, JEFF ALLAN (CHW)
Entity type:Individual
Prefix:
First Name:JEFF
Middle Name:ALLAN
Last Name:WIESINGER
Suffix:
Gender:M
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 24TH ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4450
Mailing Address - Country:US
Mailing Address - Phone:907-317-5923
Mailing Address - Fax:971-374-2551
Practice Address - Street 1:2870 BROADWAY ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97303-6500
Practice Address - Country:US
Practice Address - Phone:971-387-6918
Practice Address - Fax:971-374-2551
Is Sole Proprietor?:No
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000108072172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker