Provider Demographics
NPI:1194013771
Name:WILDHABER, JENNIFER (ATR LCPC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WILDHABER
Suffix:
Gender:F
Credentials:ATR LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 E US HIGHWAY 40 STE D
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:IL
Mailing Address - Zip Code:62294-2267
Mailing Address - Country:US
Mailing Address - Phone:618-979-2336
Mailing Address - Fax:618-505-5044
Practice Address - Street 1:189 E US HIGHWAY 40 STE D
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:IL
Practice Address - Zip Code:62294-2267
Practice Address - Country:US
Practice Address - Phone:618-979-2336
Practice Address - Fax:618-505-5044
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-15
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178007168101YP2500X
IL180007942101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional