Provider Demographics
NPI:1962879833
Name:WIENS, JENNIFER DIANNE (PSYD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:DIANNE
Last Name:WIENS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 E KENNEDY BLVD UNIT 1019
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-3587
Mailing Address - Country:US
Mailing Address - Phone:813-336-9244
Mailing Address - Fax:
Practice Address - Street 1:11035 NE SANDY BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-2553
Practice Address - Country:US
Practice Address - Phone:503-258-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-27
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY10631103T00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health