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General NPI Number Information
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NPI Number | 1487312427
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Entity Type | Individual
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Provider Name | JACQUELINE THERESE WIRTH DNP, APRN, CPNP-PC
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Gender | Female
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Dates
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Enumeration Date | 12/07/2021
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Last Update Date | 12/07/2021
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Provider Practice Location Address
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Address Line | 1680 MEDITERRANEAN DR STE 107
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City | SYCAMORE
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State | IL
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Zip | 60178-3193
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Country | US
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Telephone | 815-899-0001
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Fax |
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Provider Business Mailing Address
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Address Line | 19304 MIDLAND AVE
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City | MOKENA
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State | IL
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Zip | 60448-1118
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Country | US
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Telephone | 815-685-3572
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0200X
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Taxonomy Name | Pediatric Nurse Practitioner
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License Number | 209024208
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License Number State | IL
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