Provider Demographics
NPI:1386334217
Name:WILDE, JACQUELINE MICHAEL (LMFT)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MICHAEL
Last Name:WILDE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:JAX
Other - Middle Name:MICHAEL
Other - Last Name:WILDE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMFT
Mailing Address - Street 1:2107 SIESTA LN
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-3238
Mailing Address - Country:US
Mailing Address - Phone:707-331-9658
Mailing Address - Fax:
Practice Address - Street 1:2107 SIESTA LN
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-3238
Practice Address - Country:US
Practice Address - Phone:707-331-9658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46715101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health