Provider Demographics
NPI:1073991394
Name:WILSON, JENNIFER ERIN (MC, CP)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:ERIN
Last Name:WILSON
Suffix:
Gender:F
Credentials:MC, CP
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:ERIN
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LMHCA, CDP
Mailing Address - Street 1:1950 ALASKAN WAY
Mailing Address - Street 2:#422
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-1075
Mailing Address - Country:US
Mailing Address - Phone:206-383-5309
Mailing Address - Fax:206-302-2210
Practice Address - Street 1:2743 CALIFORNIA AVE SW
Practice Address - Street 2:SUITE 301
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98116-2495
Practice Address - Country:US
Practice Address - Phone:206-383-5309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-07
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC 60547904101YM0800X
WACP60627320101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)