Provider Demographics
NPI:1144255712
Name:WIESELQUIST, JESSICA (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WIESELQUIST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 RESEARCH PL
Mailing Address - Street 2:SUITE 130
Mailing Address - City:NORTH CHELMSFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01863-2454
Mailing Address - Country:US
Mailing Address - Phone:978-446-9850
Mailing Address - Fax:855-283-4714
Practice Address - Street 1:20 RESEARCH PL
Practice Address - Street 2:SUITE 130
Practice Address - City:NORTH CHELMSFORD
Practice Address - State:MA
Practice Address - Zip Code:01863-2454
Practice Address - Country:US
Practice Address - Phone:978-446-9850
Practice Address - Fax:855-283-4714
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA161137207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2021366Medicaid
G97976Medicare UPIN
A29867Medicare ID - Type Unspecified