Healthcare Provider Details

I. General information

NPI: 1285771451
Provider Name (Legal Business Name): JENNIFER S. WIEGAND LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 12/14/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19063 12TH AVE NE
POULSBO WA
98370-7334
US

IV. Provider business mailing address

19063 12TH AVE NE
POULSBO WA
98370-7334
US

V. Phone/Fax

Practice location:
  • Phone: 360-779-7956
  • Fax: 360-697-1319
Mailing address:
  • Phone: 360-779-7956
  • Fax: 360-697-1319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMAOOO20316
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: