Provider Demographics
NPI:1538848304
Name:WIEBERG, JENNA MARIE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JENNA
Middle Name:MARIE
Last Name:WIEBERG
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 BROWN RD
Mailing Address - Street 2:
Mailing Address - City:TUSCUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65082-2312
Mailing Address - Country:US
Mailing Address - Phone:573-821-3822
Mailing Address - Fax:
Practice Address - Street 1:30 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:CAMDENTON
Practice Address - State:MO
Practice Address - Zip Code:65020-7108
Practice Address - Country:US
Practice Address - Phone:573-317-9660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20190306411835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist