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General NPI Number Information
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NPI Number | 1164677738
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Entity Type | Individual
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Provider Name | JENNIFER MARIE HEBRON WILDE LISCW
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Gender | Female
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Dates
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Enumeration Date | 11/24/2008
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Last Update Date | 06/22/2021
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Provider Practice Location Address
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Address Line | 1424 NE 155TH ST SUITE 207
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City | SHORELINE
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State | WA
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Zip | 98155-7104
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Country | US
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Telephone | 858-598-3713
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Fax |
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Provider Business Mailing Address
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Address Line | 1007 39TH AVE SE
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City | PUYALLUP
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State | WA
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Zip | 98374-2192
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Country | US
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Telephone | 253-435-3100
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Fax | 253-435-3138
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LW60543263
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License Number State | WA
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