Provider Demographics
NPI:1316198971
Name:WILSON, JASON LYN (MED, LPC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:LYN
Last Name:WILSON
Suffix:
Gender:M
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N 14TH ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:OK
Mailing Address - Zip Code:73542-5829
Mailing Address - Country:US
Mailing Address - Phone:405-833-0680
Mailing Address - Fax:
Practice Address - Street 1:201 N 14TH ST
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:OK
Practice Address - Zip Code:73542-5829
Practice Address - Country:US
Practice Address - Phone:405-833-0680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-01
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3985101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health