Provider Demographics
NPI:1114076460
Name:WILSON, JENNIFER MARY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MARY
Last Name:WILSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 WALWORTH ST
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:WI
Mailing Address - Zip Code:53585-9606
Mailing Address - Country:US
Mailing Address - Phone:262-337-1702
Mailing Address - Fax:
Practice Address - Street 1:5702 ELAINE DR
Practice Address - Street 2:SUITE A
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2458
Practice Address - Country:US
Practice Address - Phone:815-601-3981
Practice Address - Fax:815-399-1959
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL71007181103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical