Basic Information
| Provider Information | |||||||||
| NPI: | 1366775124 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILCZAK | ||||||||
| FirstName: | VANESSA | ||||||||
| MiddleName: | JACLYN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4831 FLORIDA CLUB CIR APT 2203 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322161088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042640400 | ||||||||
| FaxNumber: | 9042640401 | ||||||||
| Practice Location | |||||||||
| Address1: | 1564 KINGSLEY AVE | ||||||||
| Address2: | CLAY PAIN CENTER | ||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320734511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042640400 | ||||||||
| FaxNumber: | 9042640401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2009 | ||||||||
| LastUpdateDate: | 09/11/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | CH9776 | FL | Y | Chiropractic Providers | Chiropractor | 111N00000X | X011698 | NY | N | Chiropractic Providers | Chiropractor | 111N00000X | 2009008265 | MO | N | Chiropractic Providers | Chiropractor |
No ID Information.