Provider Demographics
NPI:1437683943
Name:WILDER, JENNA
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:WILDER
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 1:113 PARK PL
Mailing Address - Street 2:
Mailing Address - City:SCHOHARIE
Mailing Address - State:NY
Mailing Address - Zip Code:12157-5211
Mailing Address - Country:US
Mailing Address - Phone:518-295-8336
Mailing Address - Fax:518-295-8724
Practice Address - Street 1:113 PARK PL
Practice Address - Street 2:
Practice Address - City:SCHOHARIE
Practice Address - State:NY
Practice Address - Zip Code:12157-5211
Practice Address - Country:US
Practice Address - Phone:518-295-8336
Practice Address - Fax:518-295-8724
Is Sole Proprietor?:No
Enumeration Date:2017-04-12
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NY101568104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03004280Medicaid