Provider Demographics
NPI:1497996052
Name:WIRKUS, JOLENE PEGGY (PSYD)
Entity Type:Individual
Prefix:
First Name:JOLENE
Middle Name:PEGGY
Last Name:WIRKUS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 E LUVERNE ST
Mailing Address - Street 2:PO BOX 686
Mailing Address - City:LUVERNE
Mailing Address - State:MN
Mailing Address - Zip Code:56156-1610
Mailing Address - Country:US
Mailing Address - Phone:507-283-9511
Mailing Address - Fax:507-283-9511
Practice Address - Street 1:9 4TH STREET
Practice Address - Street 2:
Practice Address - City:WINDOM
Practice Address - State:MN
Practice Address - Zip Code:56101
Practice Address - Country:US
Practice Address - Phone:507-831-2090
Practice Address - Fax:507-831-0185
Is Sole Proprietor?:No
Enumeration Date:2009-03-11
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5052103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical