Provider Demographics
NPI:1184276974
Name:WINGATE, JESSE ALEXANDER (MS)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:ALEXANDER
Last Name:WINGATE
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17068 LANKFORD HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:EASTVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23347
Mailing Address - Country:US
Mailing Address - Phone:573-311-0867
Mailing Address - Fax:
Practice Address - Street 1:17068 LANKFORD HIGHWAY
Practice Address - Street 2:
Practice Address - City:EASTVILLE
Practice Address - State:VA
Practice Address - Zip Code:23347-2334
Practice Address - Country:US
Practice Address - Phone:757-331-1086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0810007314103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program