MEDICARE: JENNIFER MAE WIESE MA, LPC-MH, LAC

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	LPC-MH2259	SD

General Provider Information

NPI Number	:	1801222138
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER MAE WIESE MA, LPC-MH, LAC

Provider Business Mailing Address
First Line	:	4400 W 69TH ST STE 100
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57108-8172
Country	:	US
Telephone Number	:	605-322-5924
Fax Number	:	605-322-4009

Provider Business Practice Location Address
First Line	:	4400 W 69TH ST STE 100
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57108-8172
Country	:	US
Telephone Number	:	605-322-5924
Fax Number	:	605-322-4009

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

Provider Enumeration Date	:	09/18/2013
Last Update Date	:	05/01/2019

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