Healthcare Provider Details

I. General information

NPI: 1134828619
Provider Name (Legal Business Name): STEPHANIE WIELGOSZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2023
Last Update Date: 02/23/2023
Certification Date: 02/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5422 CLINTON BLVD
JACKSON MS
39209-3050
US

IV. Provider business mailing address

5422 CLINTON BLVD
JACKSON MS
39209-3050
US

V. Phone/Fax

Practice location:
  • Phone: 601-724-5040
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP-0543
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: