Provider Demographics
NPI:1487312427
Name:WIRTH, JACQUELINE THERESE (DNP, APRN, CPNP-PC)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:THERESE
Last Name:WIRTH
Suffix:
Gender:F
Credentials:DNP, APRN, CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19304 MIDLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-1118
Mailing Address - Country:US
Mailing Address - Phone:815-685-3572
Mailing Address - Fax:
Practice Address - Street 1:1680 MEDITERRANEAN DR STE 107
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3193
Practice Address - Country:US
Practice Address - Phone:815-899-0001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209024208363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics