Provider Demographics
NPI:1295232825
Name:WIELAND, JACQUELINE (LSW)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:WIELAND
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1127 EUCLID AVE APT 906
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44115-1613
Mailing Address - Country:US
Mailing Address - Phone:612-201-7686
Mailing Address - Fax:
Practice Address - Street 1:1127 EUCLID AVE APT 906
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-1613
Practice Address - Country:US
Practice Address - Phone:612-201-7686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-10
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN101Y00000X
175T00000X
S.2106437104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No175T00000XOther Service ProvidersPeer Specialist