Provider Demographics
NPI:1932922770
Name:WERTZ, JEFF (MA)
Entity type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:WERTZ
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 S. INDIANA AVE
Mailing Address - Street 2:DOOR F
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526
Mailing Address - Country:US
Mailing Address - Phone:574-533-3151
Mailing Address - Fax:574-534-9159
Practice Address - Street 1:1216 S. INDIANA AVE
Practice Address - Street 2:DOOR F
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526
Practice Address - Country:US
Practice Address - Phone:574-533-3151
Practice Address - Fax:574-534-9159
Is Sole Proprietor?:No
Enumeration Date:2024-10-31
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1231375103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool