Provider Demographics
NPI:1477292225
Name:WISE, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:JESSICA
Other - Middle Name:F
Other - Last Name:WISE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2324 N ZION RD STE 112
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-2575
Mailing Address - Country:US
Mailing Address - Phone:443-496-0245
Mailing Address - Fax:410-443-0842
Practice Address - Street 1:2324 N ZION RD STE 112
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-2575
Practice Address - Country:US
Practice Address - Phone:800-867-2395
Practice Address - Fax:410-443-0842
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD28567101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health