Provider Demographics
NPI:1326330135
Name:WELLER, JENNIFER MARIE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARIE
Last Name:WELLER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5444 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-2731
Mailing Address - Country:US
Mailing Address - Phone:309-781-6512
Mailing Address - Fax:
Practice Address - Street 1:306 46TH AVE
Practice Address - Street 2:
Practice Address - City:EAST MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61244-4281
Practice Address - Country:US
Practice Address - Phone:309-796-2329
Practice Address - Fax:309-796-1146
Is Sole Proprietor?:No
Enumeration Date:2011-05-11
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAP46329164W00000X
IL043.086635164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse