Provider Demographics
NPI:1730779372
Name:WIEDEMAN, JAEHYEA
Entity type:Individual
Prefix:
First Name:JAEHYEA
Middle Name:
Last Name:WIEDEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:ORLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95963-9533
Mailing Address - Country:US
Mailing Address - Phone:530-966-6480
Mailing Address - Fax:
Practice Address - Street 1:2940 EAST ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:CA
Practice Address - Zip Code:96007-3411
Practice Address - Country:US
Practice Address - Phone:530-378-5566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70524183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist