Provider Demographics
NPI:1366203820
Name:WIESE, JILLIAN MARIE (LMSW)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:MARIE
Last Name:WIESE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 5TH ST STE 270
Mailing Address - Street 2:
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-2933
Mailing Address - Country:US
Mailing Address - Phone:319-800-9046
Mailing Address - Fax:319-449-3845
Practice Address - Street 1:555 CAMERON WAY UNIT 2
Practice Address - Street 2:
Practice Address - City:NORTH LIBERTY
Practice Address - State:IA
Practice Address - Zip Code:52317-4901
Practice Address - Country:US
Practice Address - Phone:319-804-9312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA101399104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker