Healthcare Provider Details

I. General information

NPI: 1447280847
Provider Name (Legal Business Name): JESSICA A WENTZELL OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA A BOWERS OD

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 WILLMAR AVE SW AFFILIATED COMMUNITY MEDICAL CENTERS
WILLMAR MN
56201
US

IV. Provider business mailing address

101 WILLMAR AVE SW
WILLMAR MN
56201
US

V. Phone/Fax

Practice location:
  • Phone: 320-231-5000
  • Fax: 320-231-5067
Mailing address:
  • Phone: 320-231-5000
  • Fax: 320-231-5067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2958
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: