Provider Demographics
NPI:1093120677
Name:WILSON, JENNIFER WENTWORTH (LCADC, LCSWC)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:WENTWORTH
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCADC, LCSWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16528 FALLS RD
Mailing Address - Street 2:
Mailing Address - City:UPPERCO
Mailing Address - State:MD
Mailing Address - Zip Code:21155-9483
Mailing Address - Country:US
Mailing Address - Phone:410-868-0001
Mailing Address - Fax:
Practice Address - Street 1:16528 FALLS RD
Practice Address - Street 2:
Practice Address - City:UPPERCO
Practice Address - State:MD
Practice Address - Zip Code:21155-9483
Practice Address - Country:US
Practice Address - Phone:410-868-0001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCA2105101YA0400X
MD180281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)