Provider Demographics
NPI:1508298910
Name:WAHLGREN, JEZERE
Entity Type:Individual
Prefix:
First Name:JEZERE
Middle Name:
Last Name:WAHLGREN
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 1:1664 BROADWAY
Mailing Address - Street 2:HALCYON CENTER
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1664 BROADWAY
Practice Address - Street 2:HALCYON CENTER
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021
Practice Address - Country:US
Practice Address - Phone:619-722-7531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-07
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health