Basic Information
| Provider Information | |||||||||
| NPI: | 1437384708 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WUNDERLICH | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 335 GLESSNER AVE | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449032269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195268000 | ||||||||
| FaxNumber: | 4195268834 | ||||||||
| Practice Location | |||||||||
| Address1: | 199 W. MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448750000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193425015 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2009 | ||||||||
| LastUpdateDate: | 06/14/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 35.120343 | OH | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.