Healthcare Provider Details

I. General information

NPI: 1518674993
Provider Name (Legal Business Name): WENTWORTH MFT PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2022
Last Update Date: 11/03/2022
Certification Date: 11/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 YELM AVE W
YELM WA
98597-8036
US

IV. Provider business mailing address

313 YELM AVE W
YELM WA
98597-8036
US

V. Phone/Fax

Practice location:
  • Phone: 360-960-0441
  • Fax:
Mailing address:
  • Phone: 360-960-0441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER WENTWORTH
Title or Position: THERAPIST/OWNER
Credential: LMFT MHP SUDPT
Phone: 360-960-0441