Provider Demographics
NPI:1710662481
Name:WENZELBURGER, JASEN KYLE
Entity Type:Individual
Prefix:
First Name:JASEN
Middle Name:KYLE
Last Name:WENZELBURGER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3510 STEELHAMMER DR
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-4551
Mailing Address - Country:US
Mailing Address - Phone:360-623-8020
Mailing Address - Fax:
Practice Address - Street 1:2428 W REYNOLDS AVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-4554
Practice Address - Country:US
Practice Address - Phone:360-330-9044
Practice Address - Fax:360-736-3139
Is Sole Proprietor?:No
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health