Provider Demographics
NPI:1164630018
Name:WILSON, EARL III (REV, LMFT)
Entity type:Individual
Prefix:MR
First Name:EARL
Middle Name:
Last Name:WILSON
Suffix:III
Gender:M
Credentials:REV, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 COLONIAL CIR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-3208
Mailing Address - Country:US
Mailing Address - Phone:601-899-5827
Mailing Address - Fax:
Practice Address - Street 1:6205 HANGING MOSS RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-2121
Practice Address - Country:US
Practice Address - Phone:601-982-3997
Practice Address - Fax:601-982-8933
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35001450106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist