Provider Demographics
NPI:1225641780
Name:BRUENING WENDORF, JACQUELINE MARY (LCSW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARY
Last Name:BRUENING WENDORF
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9560
Mailing Address - Fax:239-343-9624
Practice Address - Street 1:8925 COLONIAL CENTER DR STE 1000
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7813
Practice Address - Country:US
Practice Address - Phone:239-343-9560
Practice Address - Fax:239-343-9624
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-25
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW46701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical