Provider Demographics
NPI:1972835940
Name:WILDE, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WILDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:382 WEST MAIN
Mailing Address - Street 2:PO BOX 318
Mailing Address - City:DUCHESNE
Mailing Address - State:UT
Mailing Address - Zip Code:84021
Mailing Address - Country:US
Mailing Address - Phone:435-738-2040
Mailing Address - Fax:
Practice Address - Street 1:382 WEST MAIN
Practice Address - Street 2:
Practice Address - City:DUCHESNE
Practice Address - State:UT
Practice Address - Zip Code:84021
Practice Address - Country:US
Practice Address - Phone:435-738-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-02
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT284410-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical