Provider Demographics
NPI:1679628689
Name:WESNER, AMY JO (MA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JO
Last Name:WESNER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5455 ALMIRA DR SE
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98311-8330
Mailing Address - Country:US
Mailing Address - Phone:360-373-5031
Mailing Address - Fax:
Practice Address - Street 1:450 S KITSAP BLVD
Practice Address - Street 2:STE 2600
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-3773
Practice Address - Country:US
Practice Address - Phone:360-415-5868
Practice Address - Fax:360-415-5872
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00007870101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA91102010689OtherKITSAP PHYSICIANS SERVICE