Healthcare Provider Details

I. General information

NPI: 1578496972
Provider Name (Legal Business Name): JACOB WIESEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 S 4TH ST STE 100
SEWARD NE
68434-2533
US

IV. Provider business mailing address

528 WOODSAGE RD
SEWARD NE
68434-8113
US

V. Phone/Fax

Practice location:
  • Phone: 402-643-2931
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8212
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: