Provider Demographics
NPI:1437611902
Name:WISNIEWSKI, JILLIAN ELIZABETH
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:ELIZABETH
Last Name:WISNIEWSKI
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 1:449 PEBBLE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:SNEADS FERRY
Mailing Address - State:NC
Mailing Address - Zip Code:28460-0048
Mailing Address - Country:US
Mailing Address - Phone:910-408-9822
Mailing Address - Fax:
Practice Address - Street 1:449 PEBBLE SHORE DR
Practice Address - Street 2:
Practice Address - City:SNEADS FERRY
Practice Address - State:NC
Practice Address - Zip Code:28460-0048
Practice Address - Country:US
Practice Address - Phone:910-408-9822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-03
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0129701041C0700X
NCC0136221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical