MEDICARE: MRS. JENNIFER MARIE WELLER MFT

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	106H00000X	Marriage & Family Therapist	1949	TN

General Provider Information

NPI Number	:	1679280655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNIFER MARIE WELLER MFT

Provider Business Mailing Address
First Line	:	1225 VULCAN RD
Second Line	:
City	:	RISING FAWN
State	:	GA
Zip	:	30738-2014
Country	:	US
Telephone Number	:	423-313-1231
Fax Number	:

Provider Business Practice Location Address
First Line	:	3405 PEERLESS RD NW
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37312-3431
Country	:	US
Telephone Number	:	423-650-7543
Fax Number	:

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

Provider Enumeration Date	:	10/31/2022
Last Update Date	:	11/09/2022

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