Provider Demographics
NPI:1679724652
Name:WENIGER, JESSICA (PA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WENIGER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10100 FOREST HILLS RD
Mailing Address - Street 2:
Mailing Address - City:MACHESNEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61115-8234
Mailing Address - Country:US
Mailing Address - Phone:815-713-2742
Mailing Address - Fax:815-282-8597
Practice Address - Street 1:391 S BOLINGBROOK DR
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-3411
Practice Address - Country:US
Practice Address - Phone:630-226-1006
Practice Address - Fax:630-226-9003
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003264363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085003264OtherILLINOIS PA LICENSE