Provider Demographics
NPI:1174197883
Name:WIESE, JENNA
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:WIESE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 PILLSBURY ST N
Mailing Address - Street 2:
Mailing Address - City:PILLAGER
Mailing Address - State:MN
Mailing Address - Zip Code:56473-2507
Mailing Address - Country:US
Mailing Address - Phone:218-746-4527
Mailing Address - Fax:
Practice Address - Street 1:680 PILLSBURY ST N
Practice Address - Street 2:
Practice Address - City:PILLAGER
Practice Address - State:MN
Practice Address - Zip Code:56473-2507
Practice Address - Country:US
Practice Address - Phone:218-746-4527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MN13798363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant