Provider Demographics
NPI:1912712035
Name:VANDERWEIDE, JEAN (RN)
Entity type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:
Last Name:VANDERWEIDE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:JEANNIE (AKA)
Other - Middle Name:
Other - Last Name:VANDERWEIDE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:4 19TH ST NE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-3936
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 19TH ST NE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-3936
Practice Address - Country:US
Practice Address - Phone:605-884-1083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-07
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDSD-RN-R030001163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health