Provider Demographics
NPI:1134470768
Name:WEICKUM, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WEICKUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27527-8739
Mailing Address - Country:US
Mailing Address - Phone:919-879-8746
Mailing Address - Fax:503-476-2949
Practice Address - Street 1:204 COLONIAL DR
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27527-8739
Practice Address - Country:US
Practice Address - Phone:919-879-8746
Practice Address - Fax:503-476-2949
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-21
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7824101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health