Basic Information
| Provider Information | |||||||||
| NPI: | 1831795129 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WINGATE | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6726 S 1000 E | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479059443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652426461 | ||||||||
| FaxNumber: | 7655642608 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 PRINCE WILLIAM RD | ||||||||
| Address2: | |||||||||
| City: | DELPHI | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469231758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7655643016 | ||||||||
| FaxNumber: | 7655642608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2020 | ||||||||
| LastUpdateDate: | 12/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 33009830A | IN | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.