Provider Demographics
NPI:1316368756
Name:WILSON, JENNIFER (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10421 W BROWNSTONE DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-5612
Mailing Address - Country:US
Mailing Address - Phone:208-794-8240
Mailing Address - Fax:
Practice Address - Street 1:3067 E COPPER POINT DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1740
Practice Address - Country:US
Practice Address - Phone:208-888-1758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-03
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-29066101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor