Basic Information
| Provider Information | |||||||||
| NPI: | 1447586698 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIENKE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 NORTH SUNRISE AVA SUITE 1105 | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167718255 | ||||||||
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| Practice Location | |||||||||
| Address1: | 151 N SUNRISE AVE | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956612924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167718255 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2009 | ||||||||
| LastUpdateDate: | 11/17/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0200X | 4903 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics |
No ID Information.