Provider Demographics
NPI:1154713956
Name:KWASNIAK-WHEAT, JODETTE (MA, LCPC)
Entity type:Individual
Prefix:MRS
First Name:JODETTE
Middle Name:
Last Name:KWASNIAK-WHEAT
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 BUFFALO TRL
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:IL
Mailing Address - Zip Code:60510-8351
Mailing Address - Country:US
Mailing Address - Phone:630-800-9396
Mailing Address - Fax:
Practice Address - Street 1:1116 BUFFALO TRL
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:IL
Practice Address - Zip Code:60510-8351
Practice Address - Country:US
Practice Address - Phone:630-800-9396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-03
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180003956101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health