Healthcare Provider Details

I. General information

NPI: 1992435283
Provider Name (Legal Business Name): JENNIFER HOAG WYDLER LCSW, LCDC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2022
Last Update Date: 06/27/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6333 DE ZAVALA RD
SAN ANTONIO TX
78249-2115
US

IV. Provider business mailing address

5016 BRAZOSWOOD
SAN ANTONIO TX
78244-2817
US

V. Phone/Fax

Practice location:
  • Phone: 210-399-4838
  • Fax:
Mailing address:
  • Phone: 210-441-0221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number13146
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number69250
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: