Provider Demographics
NPI:1447280847
Name:WENTZELL, JESSICA A (OD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:A
Last Name:WENTZELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:A
Other - Last Name:BOWERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:101 WILLMAR AVE SW
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201
Mailing Address - Country:US
Mailing Address - Phone:320-231-5000
Mailing Address - Fax:320-231-5067
Practice Address - Street 1:101 WILLMAR AVE SW
Practice Address - Street 2:AFFILIATED COMMUNITY MEDICAL CENTERS
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201
Practice Address - Country:US
Practice Address - Phone:320-231-5000
Practice Address - Fax:320-231-5067
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2958152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist