Provider Demographics
NPI:1295164911
Name:WISNER, JACQUELINE JOAN RACHEL (MD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:JOAN RACHEL
Last Name:WISNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2208 EASTLAKE RD
Mailing Address - Street 2:
Mailing Address - City:TIMONIUM
Mailing Address - State:MD
Mailing Address - Zip Code:21093-2706
Mailing Address - Country:US
Mailing Address - Phone:410-982-8103
Mailing Address - Fax:410-252-4054
Practice Address - Street 1:2208 EASTLAKE RD
Practice Address - Street 2:
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-2706
Practice Address - Country:US
Practice Address - Phone:410-982-8103
Practice Address - Fax:410-252-4054
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD75209207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine