Provider Demographics
NPI:1245434554
Name:WANTUCK, JENNIFER MARGARET (MSW)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:MARGARET
Last Name:WANTUCK
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202-4106
Mailing Address - Country:US
Mailing Address - Phone:716-362-0020
Mailing Address - Fax:
Practice Address - Street 1:90 PEARL ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-4106
Practice Address - Country:US
Practice Address - Phone:716-362-0020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY075961104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker