Provider Demographics
NPI:1174508840
Name:WIENCEK, JEFFREY PAUL (FNP)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:PAUL
Last Name:WIENCEK
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:3723 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-7310
Practice Address - Country:US
Practice Address - Phone:219-874-3313
Practice Address - Fax:219-878-2330
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000502A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71000502AOtherLICENSE IN
INP33694Medicare UPIN
IN200332120Medicaid