Provider Demographics
NPI:1225566995
Name:WHITTLESEY-JEROME, WANDA K (MSW, LMSW, PHD)
Entity Type:Individual
Prefix:DR
First Name:WANDA
Middle Name:K
Last Name:WHITTLESEY-JEROME
Suffix:
Gender:F
Credentials:MSW, LMSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1033 W MEADOWLARK LN
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-9688
Mailing Address - Country:US
Mailing Address - Phone:505-610-6808
Mailing Address - Fax:505-896-6942
Practice Address - Street 1:10138 BOSQUE CIR NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-8827
Practice Address - Country:US
Practice Address - Phone:505-414-8467
Practice Address - Fax:505-407-0075
Is Sole Proprietor?:No
Enumeration Date:2017-05-25
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-04933104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker