Provider Demographics
NPI:1669006466
Name:WIEGAND, JACOB DEAN
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:DEAN
Last Name:WIEGAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 W TIPTON ST
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:IN
Mailing Address - Zip Code:47274-2363
Mailing Address - Country:US
Mailing Address - Phone:812-522-3429
Mailing Address - Fax:812-522-0790
Practice Address - Street 1:411 W TIPTON ST
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-2363
Practice Address - Country:US
Practice Address - Phone:812-522-2349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-02
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28195010A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered