Provider Demographics
NPI:1346278421
Name:JISKOOT, WENDELA REGINA (MSW LICSW)
Entity Type:Individual
Prefix:MS
First Name:WENDELA
Middle Name:REGINA
Last Name:JISKOOT
Suffix:
Gender:F
Credentials:MSW LICSW
Other - Prefix:MRS
Other - First Name:WENDELA
Other - Middle Name:REGINA
Other - Last Name:MCKNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:57 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:RI
Mailing Address - Zip Code:02809
Mailing Address - Country:US
Mailing Address - Phone:401-253-3130
Mailing Address - Fax:
Practice Address - Street 1:57 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:RI
Practice Address - Zip Code:02809
Practice Address - Country:US
Practice Address - Phone:401-253-3130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW000791041C0700X
MA1071361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI6212005OtherUBH
RI74841OtherBC & BS OR RI