Provider Demographics
NPI:1114276904
Name:DEWILDE, JANE SUSAN (MFTI)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:SUSAN
Last Name:DEWILDE
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:352 MAGPIE LN
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-5822
Mailing Address - Country:US
Mailing Address - Phone:714-318-4543
Mailing Address - Fax:
Practice Address - Street 1:352 MAGPIE LN
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-5822
Practice Address - Country:US
Practice Address - Phone:714-318-4543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-07
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107315106H00000X
CAIMF69176106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty