Provider Demographics
NPI:1396211033
Name:WETZEL, JACALYN
Entity Type:Individual
Prefix:
First Name:JACALYN
Middle Name:
Last Name:WETZEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2081 TRAILWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-4218
Mailing Address - Country:US
Mailing Address - Phone:919-988-0605
Mailing Address - Fax:
Practice Address - Street 1:2081 TRAILWOOD DR
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-4218
Practice Address - Country:US
Practice Address - Phone:919-988-0605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-21
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1010641041C0700X
MSC100081041C0700X
NCC0130801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical