MEDICARE: JESSICA M WIENER PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	C.1300702	OH

General Provider Information

NPI Number	:	1205236593
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA M WIENER PC

Provider Business Mailing Address
First Line	:	37658 LAKE SHORE BLVD UNIT 1
Second Line	:
City	:	EASTLAKE
State	:	OH
Zip	:	44095-1048
Country	:	US
Telephone Number	:	440-479-5145
Fax Number	:

Provider Business Practice Location Address
First Line	:	34950 CHARDON RD STE 202
Second Line	:
City	:	WILLOUGHBY HILLS
State	:	OH
Zip	:	44094-9162
Country	:	US
Telephone Number	:	440-510-5100
Fax Number	:	440-510-5151

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2014
Last Update Date	:	08/25/2014

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