Provider Demographics
NPI:1891209284
Name:JESSICA J. WOLKE LICSW INC
Entity type:Organization
Organization Name:JESSICA J. WOLKE LICSW INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:CASSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-405-4951
Mailing Address - Street 1:21 CANAL ST STE 201
Mailing Address - Street 2:
Mailing Address - City:WESTERLY
Mailing Address - State:RI
Mailing Address - Zip Code:02891-1587
Mailing Address - Country:US
Mailing Address - Phone:401-596-2475
Mailing Address - Fax:
Practice Address - Street 1:21 CANAL ST STE 201
Practice Address - Street 2:
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891-1587
Practice Address - Country:US
Practice Address - Phone:401-596-8830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-22
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW015541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIU300404468OtherMEDICARE PTAN