Provider Demographics
NPI:1689710410
Name:WIEBE, JACQUELINE ANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:ANNE
Last Name:WIEBE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:ANNE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:118 COLLEGE DR
Mailing Address - Street 2:5066
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39406
Mailing Address - Country:US
Mailing Address - Phone:601-266-5390
Mailing Address - Fax:601-266-4205
Practice Address - Street 1:118 COLLEGE DR
Practice Address - Street 2:5066
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39406
Practice Address - Country:US
Practice Address - Phone:601-266-5390
Practice Address - Fax:601-266-4205
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS159312084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
G22982Medicare UPIN