Provider Demographics
NPI:1891946877
Name:WENKEL, JACK (PA)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:WENKEL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:605C DOUGLAS DR
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:MO
Mailing Address - Zip Code:65010-9088
Mailing Address - Country:US
Mailing Address - Phone:573-657-9354
Mailing Address - Fax:573-657-9694
Practice Address - Street 1:605C DOUGLAS DR
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:MO
Practice Address - Zip Code:65010-9088
Practice Address - Country:US
Practice Address - Phone:573-657-9354
Practice Address - Fax:573-657-9694
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2008031587363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant