Healthcare Provider Details

I. General information

NPI: 1720944606
Provider Name (Legal Business Name): JACQUELINE MARIE WAHL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2026
Last Update Date: 01/05/2026
Certification Date: 01/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3651 E BASELINE RD
GILBERT AZ
85234-2689
US

IV. Provider business mailing address

6580 E MCDOWELL RD UNIT 2509
SCOTTSDALE AZ
85257-0037
US

V. Phone/Fax

Practice location:
  • Phone: 602-833-2829
  • Fax: 480-885-5621
Mailing address:
  • Phone: 760-895-9665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: