Provider Demographics
NPI:1205039070
Name:WUNDERLY, JACQUELINE ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:ALLEN
Last Name:WUNDERLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:ALLEN-WUNDERLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:10814 S INTERLAKEN
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49083-8514
Mailing Address - Country:US
Mailing Address - Phone:269-629-5231
Mailing Address - Fax:
Practice Address - Street 1:10814 S INTERLAKEN
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:MI
Practice Address - Zip Code:49083-8514
Practice Address - Country:US
Practice Address - Phone:269-629-5231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301049069207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology