Provider Demographics
NPI:1073869673
Name:WILSON, JENNIFER JUNE VILLEGAS
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JUNE VILLEGAS
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:JUNE
Other - Last Name:VILLEGAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14724 VENTURA BLVD FL 10
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-3501
Mailing Address - Country:US
Mailing Address - Phone:310-497-2669
Mailing Address - Fax:
Practice Address - Street 1:14724 VENTURA BLVD FL 10
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-3501
Practice Address - Country:US
Practice Address - Phone:310-497-2669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-01
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102769106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist