Provider Demographics
NPI:1841398229
Name:WIEBKE, JENNIFER L (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:WIEBKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:CRAIG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:811 REDGATE AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1515
Mailing Address - Country:US
Mailing Address - Phone:757-668-7874
Mailing Address - Fax:757-668-8658
Practice Address - Street 1:601 CHILDRENS LN
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1910
Practice Address - Country:US
Practice Address - Phone:757-668-9466
Practice Address - Fax:757-668-7198
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012544092080S0012X, 2080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
No2080S0012XAllopathic & Osteopathic PhysiciansPediatricsSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1801861Medicaid
OH2655158Medicaid
IN100177350Medicaid
LA1801861Medicaid
B70875Medicare UPIN