Provider Demographics
NPI:1699811471
Name:WISE, JENNIFER LEA (DC)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LEA
Last Name:WISE
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 1:4931 S ROUTE 59
Mailing Address - Street 2:UNIT 121
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-5705
Mailing Address - Country:US
Mailing Address - Phone:630-355-8022
Mailing Address - Fax:630-355-8032
Practice Address - Street 1:4931 S ROUTE 59
Practice Address - Street 2:UNIT 121
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-5705
Practice Address - Country:US
Practice Address - Phone:630-355-8022
Practice Address - Fax:630-355-8032
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009021111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL573430Medicare ID - Type Unspecified
ILK17712Medicare UPIN