1790065753 NPI number — MRS. JENNIFER NICOLE WEIDA D.C.

Table of content: MRS. JENNIFER NICOLE WEIDA D.C. (NPI 1790065753)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790065753 NPI number — MRS. JENNIFER NICOLE WEIDA D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEIDA
Provider First Name:
JENNIFER
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PRATT
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1790065753
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2517 GALA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST LAFAYETTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47906-4843
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-543-5100
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3451 WYNDHAM WAY
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
WEST LAFAYETTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47906-5508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-543-5100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/23/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  08002587A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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