Healthcare Provider Details

I. General information

NPI: 1871752436
Provider Name (Legal Business Name): JACQUELINE ANN WEYDERT LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2008
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30147 EVANS RD
ROCKY MOUNT MO
65072-2715
US

IV. Provider business mailing address

30147 EVANS RD
ROCKY MOUNT MO
65072-2715
US

V. Phone/Fax

Practice location:
  • Phone: 319-541-5320
  • Fax:
Mailing address:
  • Phone: 319-541-5320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number06609
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2013040378
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: