Provider Demographics
NPI:1679144422
Name:WILDRICK, JENNY MARIE (MS, LPC, CRC CPRP)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:MARIE
Last Name:WILDRICK
Suffix:
Gender:F
Credentials:MS, LPC, CRC CPRP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 E DRINKER ST
Mailing Address - Street 2:
Mailing Address - City:DUNMORE
Mailing Address - State:PA
Mailing Address - Zip Code:18512-2549
Mailing Address - Country:US
Mailing Address - Phone:570-851-7408
Mailing Address - Fax:
Practice Address - Street 1:629 E DRINKER ST
Practice Address - Street 2:
Practice Address - City:DUNMORE
Practice Address - State:PA
Practice Address - Zip Code:18512-2549
Practice Address - Country:US
Practice Address - Phone:570-851-7408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-02
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC013178101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional