Provider Demographics
NPI:1093009912
Name:WILSON, JENNIFER MARIE (LMFT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:MOUNT WASHINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40047-0247
Mailing Address - Country:US
Mailing Address - Phone:502-822-6861
Mailing Address - Fax:
Practice Address - Street 1:645 N BARDSTOWN RD # 247
Practice Address - Street 2:
Practice Address - City:MOUNT WASHINGTON
Practice Address - State:KY
Practice Address - Zip Code:40047-9998
Practice Address - Country:US
Practice Address - Phone:502-822-6861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-08
Last Update Date:2021-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
KY272400106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor