Provider Demographics
NPI:1073532552
Name:WEDGE, SHELLY A (LPA)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:A
Last Name:WEDGE
Suffix:
Gender:F
Credentials:LPA
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:A
Other - Last Name:JACOBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPA
Mailing Address - Street 1:PO BOX 4105
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4105
Mailing Address - Country:US
Mailing Address - Phone:866-907-1068
Mailing Address - Fax:425-917-9141
Practice Address - Street 1:2250 S WOODWORTH LOOP STE 202
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-7457
Practice Address - Country:US
Practice Address - Phone:907-761-5800
Practice Address - Fax:907-761-5801
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKPSYA411101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMH4828Medicaid