Provider Demographics
NPI:1144902289
Name:WERTZ, JACOB R
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:R
Last Name:WERTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 S 29TH ST
Mailing Address - Street 2:
Mailing Address - City:PARSONS
Mailing Address - State:KS
Mailing Address - Zip Code:67357-4401
Mailing Address - Country:US
Mailing Address - Phone:620-778-1885
Mailing Address - Fax:
Practice Address - Street 1:802 S 29TH ST
Practice Address - Street 2:
Practice Address - City:PARSONS
Practice Address - State:KS
Practice Address - Zip Code:67357-4401
Practice Address - Country:US
Practice Address - Phone:620-778-1885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13290-T104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker