Provider Demographics
NPI:1508257288
Name:WETTENGEL, JASON (PHARMD)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:
Last Name:WETTENGEL
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 SHAWANO AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-2606
Mailing Address - Country:US
Mailing Address - Phone:920-496-8110
Mailing Address - Fax:
Practice Address - Street 1:2015 SHAWANO AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2606
Practice Address - Country:US
Practice Address - Phone:920-496-8110
Practice Address - Fax:920-496-8165
Is Sole Proprietor?:No
Enumeration Date:2015-02-16
Last Update Date:2017-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17697-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist