Provider Demographics
NPI:1013497791
Name:WIELICK, JACQUELINE JEANNE (MS)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:JEANNE
Last Name:WIELICK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23207 COLUMBIA POINTE LN
Mailing Address - Street 2:
Mailing Address - City:ORONDO
Mailing Address - State:WA
Mailing Address - Zip Code:98843-9826
Mailing Address - Country:US
Mailing Address - Phone:619-630-5481
Mailing Address - Fax:
Practice Address - Street 1:23207 COLUMBIA POINTE LN
Practice Address - Street 2:
Practice Address - City:ORONDO
Practice Address - State:WA
Practice Address - Zip Code:98843-9826
Practice Address - Country:US
Practice Address - Phone:619-630-5481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF100541106H00000X
CA118766106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist