Provider Demographics
NPI:1235431925
Name:WANITSCHEK-GILMER, JERRY M (LPC)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:M
Last Name:WANITSCHEK-GILMER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3702 HAWTHORNE LN
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-2631
Mailing Address - Country:US
Mailing Address - Phone:530-356-9087
Mailing Address - Fax:503-815-1870
Practice Address - Street 1:627 NE EVANS ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-3923
Practice Address - Country:US
Practice Address - Phone:503-434-7523
Practice Address - Fax:503-815-1870
Is Sole Proprietor?:No
Enumeration Date:2010-12-01
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3884101YM0800X, 101YP2500X
101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR223354Medicaid
OR500699827Medicaid