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General NPI Number Information
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NPI Number | 1366203820
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Entity Type | Individual
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Provider Name | JILLIAN MARIE WIESE LMSW
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Gender | Female
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Dates
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Enumeration Date | 01/22/2024
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Last Update Date | 01/22/2024
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Provider Practice Location Address
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Address Line | 555 CAMERON WAY UNIT 2
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City | NORTH LIBERTY
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State | IA
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Zip | 52317-4901
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Country | US
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Telephone | 319-804-9312
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Fax |
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Provider Business Mailing Address
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Address Line | 1150 5TH ST STE 270
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City | CORALVILLE
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State | IA
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Zip | 52241-2933
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Country | US
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Telephone | 319-800-9046
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Fax | 319-449-3845
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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 | 104100000X
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Taxonomy Name | Social Worker
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License Number | 101399
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License Number State | IA
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