Provider Demographics
NPI:1366127508
Name:WASIK, JENNIFER J (PLMHC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:J
Last Name:WASIK
Suffix:
Gender:F
Credentials:PLMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4982 RIDGEMOOR CIR
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34685-3153
Mailing Address - Country:US
Mailing Address - Phone:727-332-9224
Mailing Address - Fax:
Practice Address - Street 1:4982 RIDGEMOOR CIR
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34685-3153
Practice Address - Country:US
Practice Address - Phone:727-332-9224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-15
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1901101YM0800X
FLMH22498101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health