Provider Demographics
NPI:1801222138
Name:WIESE, JENNIFER MAE (MA, LPC-MH, LAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MAE
Last Name:WIESE
Suffix:
Gender:F
Credentials:MA, LPC-MH, LAC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MAE
Other - Last Name:LOVIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4400 W 69TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-8172
Mailing Address - Country:US
Mailing Address - Phone:605-322-5924
Mailing Address - Fax:605-322-4009
Practice Address - Street 1:4400 W 69TH ST STE 100
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-8172
Practice Address - Country:US
Practice Address - Phone:605-322-5924
Practice Address - Fax:605-322-4009
Is Sole Proprietor?:No
Enumeration Date:2013-09-18
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLPC-MH2259101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health