Provider Demographics
NPI:1568179828
Name:WIECK, JENNIFER E (LPC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:E
Last Name:WIECK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10136 E SOUTHERN AVE UNIT 1056
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-2739
Mailing Address - Country:US
Mailing Address - Phone:319-432-1351
Mailing Address - Fax:
Practice Address - Street 1:14300 N NORTHSIGHT BLVD STE 101
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-3673
Practice Address - Country:US
Practice Address - Phone:602-550-0175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-04
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-16750101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty