Provider Demographics
NPI:1356045389
Name:WEIDENBACH, JENNA ANNE
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:ANNE
Last Name:WEIDENBACH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20170 WAGON BOX RD
Mailing Address - Street 2:
Mailing Address - City:WHITEWOOD
Mailing Address - State:SD
Mailing Address - Zip Code:57793-6436
Mailing Address - Country:US
Mailing Address - Phone:605-484-4634
Mailing Address - Fax:
Practice Address - Street 1:353 FAIRMONT BLVD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7375
Practice Address - Country:US
Practice Address - Phone:605-755-8222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-27
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant