MEDICARE: JILL BARBARA WIENER PSYD, 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	LCS5278	CA

General Provider Information

NPI Number	:	1972633329
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JILL BARBARA WIENER PSYD, LCSW

Provider Business Mailing Address
First Line	:	940 AVENUE 64
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91105-2711
Country	:	US
Telephone Number	:	323-254-2274
Fax Number	:

Provider Business Practice Location Address
First Line	:	601 WILSHIRE BLVD STE 309
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90017-3207
Country	:	US
Telephone Number	:	310-741-1127
Fax Number	:

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

Provider Enumeration Date	:	03/06/2007
Last Update Date	:	08/21/2019

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