Healthcare Provider Details

I. General information

NPI: 1225975253
Provider Name (Legal Business Name): KYMBERLY JAY WIEDENKELLER MA, MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 S RANDALL RD # 808
ELGIN IL
60123-5529
US

IV. Provider business mailing address

209 KELSEY RD
LAKE BARRINGTON IL
60010-1557
US

V. Phone/Fax

Practice location:
  • Phone: 847-595-0662
  • Fax:
Mailing address:
  • Phone: 310-429-1974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number208001353
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: