MEDICARE: JACKIE WIEDEMANN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	333007	CA

General Provider Information

NPI Number	:	1780731778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKIE WIEDEMANN

Provider Business Mailing Address
First Line	:	1 HARPST ST
Second Line	:
City	:	ARCATA
State	:	CA
Zip	:	95521-8222
Country	:	US
Telephone Number	:	707-826-3146
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 HARPST ST
Second Line	:
City	:	ARCATA
State	:	CA
Zip	:	95521-8222
Country	:	US
Telephone Number	:	707-826-3146
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/04/2007
Last Update Date	:	07/08/2007

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