Healthcare Provider Details

I. General information

NPI: 1609187590
Provider Name (Legal Business Name): JACLYN BETH WIERZBICKI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2010
Last Update Date: 08/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 DELNOR DR
GENEVA IL
60134-4220
US

IV. Provider business mailing address

25 N WINFIELD RD
WINFIELD IL
60190-1295
US

V. Phone/Fax

Practice location:
  • Phone: 630-668-0833
  • Fax: 630-208-4373
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD-43580
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036143159
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: