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General NPI Number Information
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NPI Number | 1851648711
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Entity Type | Individual
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Provider Name | JILL RENEE WAITE CSW
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Gender | Female
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Dates
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Enumeration Date | 08/10/2012
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Last Update Date | 08/21/2012
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Provider Practice Location Address
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Address Line | 102 GRAND SEASONS DR
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City | WAUPACA
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State | WI
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Zip | 54981-8298
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Country | US
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Telephone | 715-256-3419
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Fax | 715-258-2994
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Provider Business Mailing Address
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Address Line | 102 GRAND SEASONS DR
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City | WAUPACA
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State | WI
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Zip | 54981-8298
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Country | US
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Telephone | 715-256-3419
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Fax | 715-258-2994
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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 | 10975120
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License Number State | WI
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