Healthcare Provider Details

I. General information

NPI: 1538083282
Provider Name (Legal Business Name): JACK THOMAS WENNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

7520 S GRAND ARBOR CT STE 145
SIOUX FALLS SD
57108-3456
US

IV. Provider business mailing address

5150 S ARIZONA DR APT 314
SIOUX FALLS SD
57108-2336
US

V. Phone/Fax

Practice location:
  • Phone: 605-310-0032
  • Fax:
Mailing address:
  • Phone: 507-217-6564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: