Provider Demographics
NPI:1326735341
Name:WISNER, JAUNRU ALEXANDER
Entity Type:Individual
Prefix:
First Name:JAUNRU
Middle Name:ALEXANDER
Last Name:WISNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 E GLENN ST APT 11
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-5230
Mailing Address - Country:US
Mailing Address - Phone:818-645-8980
Mailing Address - Fax:
Practice Address - Street 1:3100 W RAY RD STE 201
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-2472
Practice Address - Country:US
Practice Address - Phone:818-645-8980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBACB701417106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician