Provider Demographics
NPI:1871665893
Name:WHARTON, JEAN ANN (PHD)
Entity type:Individual
Prefix:DR
First Name:JEAN
Middle Name:ANN
Last Name:WHARTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:LA CONNER
Mailing Address - State:WA
Mailing Address - Zip Code:98257-0249
Mailing Address - Country:US
Mailing Address - Phone:360-466-4826
Mailing Address - Fax:360-466-4826
Practice Address - Street 1:509 SOUTH SECOND STREET
Practice Address - Street 2:
Practice Address - City:LACONNER
Practice Address - State:WA
Practice Address - Zip Code:98257
Practice Address - Country:US
Practice Address - Phone:360-466-4826
Practice Address - Fax:360-466-4826
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
35454OtherTRICARE