Provider Demographics
NPI:1144343625
Name:WILSON PSYCHOLOGICAL SERVICES INC
Entity type:Organization
Organization Name:WILSON PSYCHOLOGICAL SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:815-601-3981
Mailing Address - Street 1:240 WALWORTH ST
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:WI
Mailing Address - Zip Code:53585-9606
Mailing Address - Country:US
Mailing Address - Phone:815-601-3981
Mailing Address - Fax:815-399-1959
Practice Address - Street 1:5702 ELAINE DR
Practice Address - Street 2:SUITE A
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2458
Practice Address - Country:US
Practice Address - Phone:815-601-3981
Practice Address - Fax:815-399-1959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.007181103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty