Provider Demographics
NPI:1386211407
Name:WILDER, JEREMEY ALAN (LLPC)
Entity Type:Individual
Prefix:
First Name:JEREMEY
Middle Name:ALAN
Last Name:WILDER
Suffix:
Gender:M
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12585 CANTERBURY CT
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-8353
Mailing Address - Country:US
Mailing Address - Phone:616-844-3387
Mailing Address - Fax:
Practice Address - Street 1:41 WASHINGTON AVE STE 368
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-1378
Practice Address - Country:US
Practice Address - Phone:616-844-3387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI640109402101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health