Provider Demographics
NPI:1427656776
Name:WEGENER, JACQUELINE SUE
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:SUE
Last Name:WEGENER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:HUMPHREY
Mailing Address - State:NE
Mailing Address - Zip Code:68642-3105
Mailing Address - Country:US
Mailing Address - Phone:402-993-2991
Mailing Address - Fax:
Practice Address - Street 1:703 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:NE
Practice Address - Zip Code:68748-6009
Practice Address - Country:US
Practice Address - Phone:402-454-3723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1418208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation