Provider Demographics
NPI:1063643567
Name:WILSON CLINICAL SERVICES, PLLC.
Entity Type:Organization
Organization Name:WILSON CLINICAL SERVICES, PLLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESCRIBING MEDICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:A B
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, ABPP, MSCP
Authorized Official - Phone:253-200-0255
Mailing Address - Street 1:1117 A ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-5003
Mailing Address - Country:US
Mailing Address - Phone:360-339-7752
Mailing Address - Fax:
Practice Address - Street 1:1117 A ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-5003
Practice Address - Country:US
Practice Address - Phone:360-339-7752
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-31
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103G00000X, 103TC0700X, 103TP0016X
WA602937457251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty