Provider Demographics
NPI:1164677738
Name:WILDE, JENNIFER MARIE HEBRON (LISCW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE HEBRON
Last Name:WILDE
Suffix:
Gender:F
Credentials:LISCW
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:HEBRON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISCW
Mailing Address - Street 1:1007 39TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-2192
Mailing Address - Country:US
Mailing Address - Phone:253-435-3100
Mailing Address - Fax:253-435-3138
Practice Address - Street 1:1424 NE 155TH ST
Practice Address - Street 2:SUITE 207
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98155-7104
Practice Address - Country:US
Practice Address - Phone:858-598-3713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-24
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW605432631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical