MEDICARE: DR. JERRY EDWARD WESCH PH.D.

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	103TC0700X	Clinical Psychologist	071-003536	IL
2	103TH0100X	Health Service Psychologist	071-003536	IL
3	103TC0700X	Clinical Psychologist	4652	AZ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	680014846	OTHER	IL	MEDICARE RR

General Provider Information

NPI Number	:	1285629261
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERRY EDWARD WESCH PH.D.

Provider Business Mailing Address
First Line	:	2235 WHIPPET WAY
Second Line	:
City	:	SEDONA
State	:	AZ
Zip	:	86336-5905
Country	:	US
Telephone Number	:	773-875-5483
Fax Number	:

Provider Business Practice Location Address
First Line	:	2235 WHIPPET WAY
Second Line	:
City	:	SEDONA
State	:	AZ
Zip	:	86336-5905
Country	:	US
Telephone Number	:	773-875-5483
Fax Number	:

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

Provider Enumeration Date	:	09/15/2005
Last Update Date	:	09/22/2015

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