Provider Demographics
NPI:1417201708
Name:VANDEWEG, JENNIFER ROSE (LMSW)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ROSE
Last Name:VANDEWEG
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 1:5770 E HOOT OWL HOLW
Mailing Address - Street 2:
Mailing Address - City:HEREFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85615-9623
Mailing Address - Country:US
Mailing Address - Phone:706-836-8373
Mailing Address - Fax:
Practice Address - Street 1:5770 E HOOT OWL HOLW
Practice Address - Street 2:
Practice Address - City:HEREFORD
Practice Address - State:AZ
Practice Address - Zip Code:85615-9623
Practice Address - Country:US
Practice Address - Phone:706-836-8373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-08
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD184501041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool