Provider Demographics
NPI:1235800228
Name:WISNIEWSKI, JACLYN (DC)
Entity Type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:
Last Name:WISNIEWSKI
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3811 S WELLER AVE APT A303
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-5274
Mailing Address - Country:US
Mailing Address - Phone:501-339-7267
Mailing Address - Fax:
Practice Address - Street 1:5108 N 22ND ST
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-7637
Practice Address - Country:US
Practice Address - Phone:501-339-7267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021029279111NI0013X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0013XChiropractic ProvidersChiropractorIndependent Medical Examiner