Provider Demographics
NPI:1164191011
Name:WILSON, JONNIE LORRAINE
Entity Type:Individual
Prefix:
First Name:JONNIE
Middle Name:LORRAINE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:337 HARMONY CT
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-2137
Mailing Address - Country:US
Mailing Address - Phone:512-665-4542
Mailing Address - Fax:
Practice Address - Street 1:136 E SAN ANTONIO ST STE 9
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-5509
Practice Address - Country:US
Practice Address - Phone:512-665-4542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX82305101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health