Healthcare Provider Details

I. General information

NPI: 1205317906
Provider Name (Legal Business Name): JACK WILDWOOD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2018
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 GALLERY LN
MORRISVILLE VT
05661-9057
US

IV. Provider business mailing address

PO BOX 287
HYDE PARK VT
05655-0287
US

V. Phone/Fax

Practice location:
  • Phone: 802-505-9044
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number097.0135245
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: