Provider Demographics
NPI:1639393143
Name:WOOTTON, JANE MEREDITH (PHD)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:MEREDITH
Last Name:WOOTTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 739
Mailing Address - Street 2:
Mailing Address - City:LOUISA
Mailing Address - State:VA
Mailing Address - Zip Code:23093-0739
Mailing Address - Country:US
Mailing Address - Phone:505-255-8867
Mailing Address - Fax:505-933-7530
Practice Address - Street 1:102 ELM AVE
Practice Address - Street 2:
Practice Address - City:LOUISA
Practice Address - State:VA
Practice Address - Zip Code:23093
Practice Address - Country:US
Practice Address - Phone:505-225-8867
Practice Address - Fax:505-933-7530
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2022-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1302103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA20-1490303OtherTAX ID (EIN)