Provider Demographics
NPI:1033418611
Name:WILSON, JEANINE MICHELLE (LICSW)
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:MICHELLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4809 COLONEL BROOKE CT
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-2872
Mailing Address - Country:US
Mailing Address - Phone:410-507-8183
Mailing Address - Fax:301-780-3271
Practice Address - Street 1:4809 COLONEL BROOKE CT
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-2872
Practice Address - Country:US
Practice Address - Phone:410-507-8183
Practice Address - Fax:301-780-3271
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-22
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500789651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical