MEDICARE: JACK WILDWOOD PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	097.0135245	VT

General Provider Information

NPI Number	:	1205317906
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK WILDWOOD PHD

Provider Business Mailing Address
First Line	:	PO BOX 287
Second Line	:
City	:	HYDE PARK
State	:	VT
Zip	:	05655-0287
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	133 GALLERY LN
Second Line	:
City	:	MORRISVILLE
State	:	VT
Zip	:	05661-9057
Country	:	US
Telephone Number	:	802-505-9044
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2018
Last Update Date	:	12/17/2025

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