Provider Demographics
NPI:1164209375
Name:WILSON, VALENCIA JANEE
Entity Type:Individual
Prefix:
First Name:VALENCIA
Middle Name:JANEE
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 1:142B CUMBERLAND RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-6700
Mailing Address - Country:US
Mailing Address - Phone:601-209-8587
Mailing Address - Fax:
Practice Address - Street 1:142B CUMBERLAND RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-6700
Practice Address - Country:US
Practice Address - Phone:601-209-8587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0009924752104100000X
MSM10316104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker