Provider Demographics
NPI:1568013647
Name:WEDGEWORTH, JUANICCA JANEEN (LMSW)
Entity Type:Individual
Prefix:
First Name:JUANICCA
Middle Name:JANEEN
Last Name:WEDGEWORTH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 PERRY HILL RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36109-3725
Mailing Address - Country:US
Mailing Address - Phone:334-272-4670
Mailing Address - Fax:334-725-2776
Practice Address - Street 1:215 PERRY HILL RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36109-3725
Practice Address - Country:US
Practice Address - Phone:334-272-4670
Practice Address - Fax:334-725-2776
Is Sole Proprietor?:No
Enumeration Date:2019-09-20
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4630G104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker