Healthcare Provider Details

I. General information

NPI: 1336085562
Provider Name (Legal Business Name): VANDER WEYST PSYCHOLOGICAL WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2026
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8015 LILIUM WAY
PLAIN CITY OH
43064-2591
US

IV. Provider business mailing address

8015 LILIUM WAY
PLAIN CITY OH
43064-2591
US

V. Phone/Fax

Practice location:
  • Phone: 763-442-0768
  • Fax:
Mailing address:
  • Phone: 763-442-0768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. JESSICA ROSE VANDER WEYST
Title or Position: LICENSED CLINICAL PSYCHOLOGIST
Credential: PSY.D., L.P.
Phone: 763-442-0768