Healthcare Provider Details

I. General information

NPI: 1619405727
Provider Name (Legal Business Name): JESSICA LIPS WANGERIN DC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2017
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 HWY 116 S
SEBASTOPOL CA
95472-4835
US

IV. Provider business mailing address

2336 WESTVIEW WAY
SANTA ROSA CA
95403-2384
US

V. Phone/Fax

Practice location:
  • Phone: 707-200-3194
  • Fax:
Mailing address:
  • Phone: 314-609-4694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number33898
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License Number33898
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number33898
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code111NP0017X
TaxonomyPediatric Chiropractor
License Number33898
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: