Provider Demographics
NPI:1174545586
Name:WYATT, JEANNETTE B (MSS)
Entity type:Individual
Prefix:PROF
First Name:JEANNETTE
Middle Name:B
Last Name:WYATT
Suffix:
Gender:F
Credentials:MSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:286 CONGRESS AVE
Mailing Address - Street 2:
Mailing Address - City:LANSDOWNE
Mailing Address - State:PA
Mailing Address - Zip Code:19050-1257
Mailing Address - Country:US
Mailing Address - Phone:610-623-9610
Mailing Address - Fax:
Practice Address - Street 1:1489 BALTIMORE PIKE
Practice Address - Street 2:BUILDING 200, SUITE 250
Practice Address - City:SPRINGFIELD
Practice Address - State:PA
Practice Address - Zip Code:19064-3958
Practice Address - Country:US
Practice Address - Phone:610-544-2110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0132361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA093963Medicare ID - Type Unspecified