Provider Demographics
NPI:1386876944
Name:WIEDERHOLD, JEFFREY EDWARD (DC)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:EDWARD
Last Name:WIEDERHOLD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7117 S WESTNEDGE AVE
Mailing Address - Street 2:SUITE #3
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-4201
Mailing Address - Country:US
Mailing Address - Phone:269-327-4813
Mailing Address - Fax:
Practice Address - Street 1:7117 S WESTNEDGE AVE
Practice Address - Street 2:SUITE #3
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-4201
Practice Address - Country:US
Practice Address - Phone:269-327-4813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-17
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009586111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor