Basic Information
Provider Information | |||||||||
NPI: | 1871000919 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WONISH-MOTTIN | ||||||||
FirstName: | JENNA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WONISH | ||||||||
OtherFirstName: | JENNA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 10901 DARMSTADT RD | ||||||||
Address2: |   | ||||||||
City: | EVANSVILLE | ||||||||
State: | IN | ||||||||
PostalCode: | 477105027 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5024302256 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 141 COMMUNICATION DR | ||||||||
Address2: |   | ||||||||
City: | HANNIBAL | ||||||||
State: | MO | ||||||||
PostalCode: | 63401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5736031460 | ||||||||
FaxNumber: | 5736031462 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/10/2018 | ||||||||
LastUpdateDate: | 01/11/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 34009559A | IN | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 2018027453 | MO | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 67300 | TX | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.