Provider Demographics
NPI:1639338767
Name:WHEELER, JENNIFER (LCSW-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WHEELER
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 401
Mailing Address - Street 2:
Mailing Address - City:PRINCESS ANNE
Mailing Address - State:MD
Mailing Address - Zip Code:21853-0401
Mailing Address - Country:US
Mailing Address - Phone:410-651-1437
Mailing Address - Fax:
Practice Address - Street 1:30632 HAMPDEN AVE
Practice Address - Street 2:
Practice Address - City:PRINCESS ANNE
Practice Address - State:MD
Practice Address - Zip Code:21853-1009
Practice Address - Country:US
Practice Address - Phone:410-651-1437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-04
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD175691041C0700X
DEQ1-00011441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119591300Medicaid
MD119591300Medicaid