Provider Demographics
NPI:1447836929
Name:WIEDERHOLD, JENNIFER RENEE (APRN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RENEE
Last Name:WIEDERHOLD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 254
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:MT
Mailing Address - Zip Code:59639-0254
Mailing Address - Country:US
Mailing Address - Phone:406-642-0546
Mailing Address - Fax:406-743-6065
Practice Address - Street 1:611 NORTH 2ND ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:MT
Practice Address - Zip Code:59639
Practice Address - Country:US
Practice Address - Phone:406-642-0546
Practice Address - Fax:406-743-6065
Is Sole Proprietor?:No
Enumeration Date:2021-03-23
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-APRN-LIC-174614363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily