MEDICARE: MRS. JESSICA RUTH WIZMAN LCSW

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	1041C0700X	Clinical Social Worker	C005634	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1669683538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JESSICA RUTH WIZMAN LCSW

Provider Business Mailing Address
First Line	:	246 HAYWOOD CT
Second Line	:
City	:	LELAND
State	:	NC
Zip	:	28451-9332
Country	:	US
Telephone Number	:	910-632-6670
Fax Number	:

Provider Business Practice Location Address
First Line	:	509 OLDE WATERFORD WAY
Second Line	:
City	:	LELAND
State	:	NC
Zip	:	28451-4125
Country	:	US
Telephone Number	:	910-632-4848
Fax Number	:

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

Provider Enumeration Date	:	05/24/2007
Last Update Date	:	10/18/2010

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