Provider Demographics
NPI:1639240484
Name:WAIDELICH, JENNIFER E (DC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:E
Last Name:WAIDELICH
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 1:408 KELLER AVE S
Mailing Address - Street 2:
Mailing Address - City:AMERY
Mailing Address - State:WI
Mailing Address - Zip Code:54001-1220
Mailing Address - Country:US
Mailing Address - Phone:715-268-9146
Mailing Address - Fax:
Practice Address - Street 1:408 KELLER AVE S
Practice Address - Street 2:
Practice Address - City:AMERY
Practice Address - State:WI
Practice Address - Zip Code:54001-1220
Practice Address - Country:US
Practice Address - Phone:715-268-9146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2425111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN60671WAOtherBCBS OF MN
MN60671WAOtherBCBS OF MN