Basic Information
| Provider Information | |||||||||
| NPI: | 1497064059 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WESENBERG | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ANN LIEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LIEN | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 811 2ND ST SE | ||||||||
| Address2: | |||||||||
| City: | LITTLE FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563453558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206317200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 811 2ND ST SE | ||||||||
| Address2: | |||||||||
| City: | LITTLE FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563453558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206317200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2010 | ||||||||
| LastUpdateDate: | 09/13/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | PERMIT22872 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.