Provider Demographics
NPI:1093179053
Name:WANGONDU, JEDIDAH (LPC)
Entity type:Individual
Prefix:MRS
First Name:JEDIDAH
Middle Name:
Last Name:WANGONDU
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:N/A
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:1605 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-4463
Mailing Address - Country:US
Mailing Address - Phone:251-621-5360
Mailing Address - Fax:251-621-5361
Practice Address - Street 1:1605 MAIN ST
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-4463
Practice Address - Country:US
Practice Address - Phone:251-621-5360
Practice Address - Fax:251-621-5361
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-06
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3418101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional