Provider Demographics
NPI:1639909682
Name:WIDJAJA, JOANNA WENAS (DC)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:WENAS
Last Name:WIDJAJA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 1ST ST STE 111
Mailing Address - Street 2:
Mailing Address - City:SERGEANT BLUFF
Mailing Address - State:IA
Mailing Address - Zip Code:51054-8532
Mailing Address - Country:US
Mailing Address - Phone:712-823-3127
Mailing Address - Fax:
Practice Address - Street 1:204 1ST ST STE 111
Practice Address - Street 2:
Practice Address - City:SERGEANT BLUFF
Practice Address - State:IA
Practice Address - Zip Code:51054-8532
Practice Address - Country:US
Practice Address - Phone:712-301-7537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-05
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA125921111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor