Provider Demographics
NPI:1780376806
Name:WENKE, JAN ELAINE (MSN, MA, PRN, LATC)
Entity type:Individual
Prefix:MRS
First Name:JAN
Middle Name:ELAINE
Last Name:WENKE
Suffix:
Gender:F
Credentials:MSN, MA, PRN, LATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 S OAK ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-6901
Mailing Address - Country:US
Mailing Address - Phone:515-460-6400
Mailing Address - Fax:
Practice Address - Street 1:1207 S OAK ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-6901
Practice Address - Country:US
Practice Address - Phone:515-460-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041374169163WX0800X
IL0960030872255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No163WX0800XNursing Service ProvidersRegistered NurseOrthopedic