Healthcare Provider Details

I. General information

NPI: 1215789664
Provider Name (Legal Business Name): JENNIE E WISDOM-FALKENSTEIN MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2024
Last Update Date: 04/01/2024
Certification Date: 04/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 N APPLE ST APT B
DUNMORE PA
18512-2446
US

IV. Provider business mailing address

209 N APPLE ST APT B
DUNMORE PA
18512-2446
US

V. Phone/Fax

Practice location:
  • Phone: 570-575-7715
  • Fax:
Mailing address:
  • Phone: 570-575-7715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: