Provider Demographics
NPI:1952718686
Name:WILD, JESSICA (MS, LMHC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WILD
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5610 CRAWFORDSVILLE RD
Mailing Address - Street 2:2201
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46224-3727
Mailing Address - Country:US
Mailing Address - Phone:317-246-4028
Mailing Address - Fax:317-243-2328
Practice Address - Street 1:5610 CRAWFORDSVILLE RD
Practice Address - Street 2:2201
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46224-3727
Practice Address - Country:US
Practice Address - Phone:317-246-4028
Practice Address - Fax:317-243-2328
Is Sole Proprietor?:No
Enumeration Date:2014-07-15
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39002619A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health