Provider Demographics
NPI:1629207261
Name:WIENKE, JEFFREY C JR (DPM CWSP)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:C
Last Name:WIENKE
Suffix:JR
Gender:M
Credentials:DPM CWSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 N 83RD ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68505-2094
Mailing Address - Country:US
Mailing Address - Phone:402-483-4485
Mailing Address - Fax:
Practice Address - Street 1:1150 N 83RD ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68505-2094
Practice Address - Country:US
Practice Address - Phone:402-483-4485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-03
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD206213E00000X
IA000820213E00000X
NE345213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47-0836558OtherTAX ID