Basic Information
| Provider Information | |||||||||
| NPI: | 1427712314 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOLFE | ||||||||
| FirstName: | JILIAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | CADC R | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2214 NE HOLLIDAY AVE | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977016033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416306961 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 23 NW GREENWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977032078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413834293 | ||||||||
| FaxNumber: | 5413834935 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2021 | ||||||||
| LastUpdateDate: | 10/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | T-21-1050 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.