Provider Demographics
NPI:1760889471
Name:WILBER, JENNIFER A (CSAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:WILBER
Suffix:
Gender:F
Credentials:CSAC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:A
Other - Last Name:METOXEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:412 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-1904
Mailing Address - Country:US
Mailing Address - Phone:715-799-3835
Mailing Address - Fax:715-799-3836
Practice Address - Street 1:N2150 KESAEHKAHTEK RD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:WI
Practice Address - Zip Code:54128-9602
Practice Address - Country:US
Practice Address - Phone:715-799-3835
Practice Address - Fax:715-799-3836
Is Sole Proprietor?:No
Enumeration Date:2014-11-24
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15867-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)