Provider Demographics
NPI:1023289873
Name:WILDE, JESSICA LYN (LCSW)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:LYN
Last Name:WILDE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:439 CORTEZ RD W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34207-1544
Mailing Address - Country:US
Mailing Address - Phone:941-755-7830
Mailing Address - Fax:941-755-5650
Practice Address - Street 1:439 CORTEZ RD W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34207-1544
Practice Address - Country:US
Practice Address - Phone:941-755-7830
Practice Address - Fax:941-755-5650
Is Sole Proprietor?:No
Enumeration Date:2008-03-20
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 81401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical