Provider Demographics
NPI:1285854364
Name:WILSON, JENNIFER (PHD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8335 IVORY LOOP
Mailing Address - Street 2:
Mailing Address - City:PEYTON
Mailing Address - State:CO
Mailing Address - Zip Code:80831-6761
Mailing Address - Country:US
Mailing Address - Phone:719-302-1276
Mailing Address - Fax:
Practice Address - Street 1:2864 S CIRCLE DR
Practice Address - Street 2:SUITE 600
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-4114
Practice Address - Country:US
Practice Address - Phone:719-314-4260
Practice Address - Fax:716-264-6614
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3042103T00000X
NM0833103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM56054556Medicaid