Provider Demographics
NPI:1982068219
Name:WRIEDT, JESSICA M (MSW, APSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:WRIEDT
Suffix:
Gender:F
Credentials:MSW, APSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6250 STATE ROAD 11
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121-4228
Mailing Address - Country:US
Mailing Address - Phone:262-903-7093
Mailing Address - Fax:
Practice Address - Street 1:93 W GENEVA ST
Practice Address - Street 2:
Practice Address - City:WILLIAMS BAY
Practice Address - State:WI
Practice Address - Zip Code:53191-9518
Practice Address - Country:US
Practice Address - Phone:262-607-6390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-12
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI104100000X
WI89891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker