Provider Demographics
NPI:1790065753
Name:WEIDA, JENNIFER NICOLE (DC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:NICOLE
Last Name:WEIDA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:PRATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2517 GALA DR
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-4843
Mailing Address - Country:US
Mailing Address - Phone:765-543-5100
Mailing Address - Fax:
Practice Address - Street 1:3451 WYNDHAM WAY
Practice Address - Street 2:SUITE A
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-5508
Practice Address - Country:US
Practice Address - Phone:765-543-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-23
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002587A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor