Provider Demographics
NPI:1053591693
Name:WENGER, JACOB J
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:J
Last Name:WENGER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2829 CALHOUN ST
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-5406
Mailing Address - Country:US
Mailing Address - Phone:413-588-8575
Mailing Address - Fax:
Practice Address - Street 1:1050 MARINA VILLAGE PKWY STE 104
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-1033
Practice Address - Country:US
Practice Address - Phone:510-340-1702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-12
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15830171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist