Provider Demographics
NPI:1366705071
Name:WIESBROCK, JEANNE A (APN, CNS)
Entity type:Individual
Prefix:
First Name:JEANNE
Middle Name:A
Last Name:WIESBROCK
Suffix:
Gender:F
Credentials:APN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 PINE ST
Mailing Address - Street 2:
Mailing Address - City:SPRING GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60081-8099
Mailing Address - Country:US
Mailing Address - Phone:815-675-9106
Mailing Address - Fax:
Practice Address - Street 1:1775 DEMPSTER ST
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1143
Practice Address - Country:US
Practice Address - Phone:847-723-7046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.009545364SN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SN0000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistNeonatal