Provider Demographics
NPI:1316358302
Name:WILSON, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
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 1:32 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02364-2255
Mailing Address - Country:US
Mailing Address - Phone:508-747-2012
Mailing Address - Fax:
Practice Address - Street 1:32 CRESCENT ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:MA
Practice Address - Zip Code:02364-2255
Practice Address - Country:US
Practice Address - Phone:508-747-2012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-13
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist