Provider Demographics
NPI:1558802603
Name:WIERSMA, JENNA (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:WIERSMA
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 HOSPITAL DR STE 202
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-7829
Mailing Address - Country:US
Mailing Address - Phone:907-419-5957
Mailing Address - Fax:
Practice Address - Street 1:3200 HOSPITAL DR STE 202
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-7829
Practice Address - Country:US
Practice Address - Phone:907-419-5957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-09
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK119981103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst