Provider Demographics
NPI:1093033599
Name:WENZKE, JEANNE M (LISW)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:M
Last Name:WENZKE
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 CAMINO DE CHELLY
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-6263
Mailing Address - Country:US
Mailing Address - Phone:505-944-5560
Mailing Address - Fax:
Practice Address - Street 1:1450 S SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4038
Practice Address - Country:US
Practice Address - Phone:505-944-5560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-07
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-07313104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM42121345Medicaid