Provider Demographics
NPI:1902409709
Name:WIRT, JENNIFER MARCELLA (LMHC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARCELLA
Last Name:WIRT
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2690 NE KRESKY AVE
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-2412
Mailing Address - Country:US
Mailing Address - Phone:360-330-9595
Mailing Address - Fax:360-330-9560
Practice Address - Street 1:300 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:RAYMOND
Practice Address - State:WA
Practice Address - Zip Code:98577-3016
Practice Address - Country:US
Practice Address - Phone:360-942-3040
Practice Address - Fax:360-942-3955
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH61306829101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2212708Medicaid