Provider Demographics
NPI:1669683538
Name:WIZMAN, JESSICA RUTH (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:RUTH
Last Name:WIZMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 HAYWOOD CT
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-9332
Mailing Address - Country:US
Mailing Address - Phone:910-632-6670
Mailing Address - Fax:
Practice Address - Street 1:509 OLDE WATERFORD WAY
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-4125
Practice Address - Country:US
Practice Address - Phone:910-632-4848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0056341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106687Medicaid
NC6106687Medicaid