MEDICARE: MRS. JENNIFER NICOLE WEIDA D.C.

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	111N00000X	Chiropractor	08002587A	IN

General Provider Information

NPI Number	:	1790065753
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNIFER NICOLE WEIDA D.C.

Provider Business Mailing Address
First Line	:	2517 GALA DR
Second Line	:
City	:	WEST LAFAYETTE
State	:	IN
Zip	:	47906-4843
Country	:	US
Telephone Number	:	765-543-5100
Fax Number	:

Provider Business Practice Location Address
First Line	:	3451 WYNDHAM WAY
Second Line	:	SUITE A
City	:	WEST LAFAYETTE
State	:	IN
Zip	:	47906-5508
Country	:	US
Telephone Number	:	765-543-5100
Fax Number	:

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

Provider Enumeration Date	:	08/23/2011
Last Update Date	:	08/23/2011

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