Provider Demographics
NPI:1275688137
Name:WILSON, KELLY L
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
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 1:200 N CONGRESS ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39201-1902
Mailing Address - Country:US
Mailing Address - Phone:601-355-8634
Mailing Address - Fax:
Practice Address - Street 1:200 N CONGRESS ST
Practice Address - Street 2:SUITE 100
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39201-1902
Practice Address - Country:US
Practice Address - Phone:601-355-8634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC5370104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08135705Medicaid