Provider Demographics
NPI:1275809576
Name:WIGGLETON, JEANETTE DIANE
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:DIANE
Last Name:WIGGLETON
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 1:3216 PENINSULA DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-0603
Mailing Address - Country:US
Mailing Address - Phone:706-814-3404
Mailing Address - Fax:706-868-6585
Practice Address - Street 1:3216 PENINSULA DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-0603
Practice Address - Country:US
Practice Address - Phone:706-814-3404
Practice Address - Fax:706-868-6585
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator