Provider Demographics
NPI:1902423833
Name:WILSON, JENNIFER LEE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 N INDIANA AVE UNIT A
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34223-2756
Mailing Address - Country:US
Mailing Address - Phone:860-917-8841
Mailing Address - Fax:
Practice Address - Street 1:655 N INDIANA AVE UNIT A
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34223-2756
Practice Address - Country:US
Practice Address - Phone:860-917-8841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician