Provider Demographics
NPI:1457979155
Name:WALLENBERG, JEFFREY (CNP-PMHNP)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:WALLENBERG
Suffix:
Gender:M
Credentials:CNP-PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 W 49TH ST STE 206
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-4219
Mailing Address - Country:US
Mailing Address - Phone:605-271-6582
Mailing Address - Fax:
Practice Address - Street 1:800 5TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51101-1317
Practice Address - Country:US
Practice Address - Phone:800-472-9018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAG1595662084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry