Provider Demographics
NPI:1104811397
Name:WENDT, JEANETTE K (MD)
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:K
Last Name:WENDT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1631 W INA RD STE 151
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-1907
Mailing Address - Country:US
Mailing Address - Phone:520-742-1833
Mailing Address - Fax:520-742-7548
Practice Address - Street 1:1631 W INA RD STE 151
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-1907
Practice Address - Country:US
Practice Address - Phone:520-742-1833
Practice Address - Fax:520-742-7548
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ170002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ270041Medicaid
AZ270041Medicaid
AZZ71993Medicare PIN