Healthcare Provider Details

I. General information

NPI: 1194313825
Provider Name (Legal Business Name): JESSICA WIGGINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2021
Last Update Date: 01/07/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 W ALGONQUIN RD
ALGONQUIN IL
60102-9401
US

IV. Provider business mailing address

4001 W ALGONQUIN RD
ALGONQUIN IL
60102-9401
US

V. Phone/Fax

Practice location:
  • Phone: 224-569-2582
  • Fax:
Mailing address:
  • Phone: 224-569-2582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number049136807
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: