Provider Demographics
NPI:1326258864
Name:WILSON, L. JANE (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:L.
Middle Name:JANE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1398 EAST 2250 NORTH ROAD
Mailing Address - Street 2:
Mailing Address - City:WHITE HEATH
Mailing Address - State:IL
Mailing Address - Zip Code:61884-0000
Mailing Address - Country:US
Mailing Address - Phone:217-687-4132
Mailing Address - Fax:217-373-1856
Practice Address - Street 1:809 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3320
Practice Address - Country:US
Practice Address - Phone:217-373-1850
Practice Address - Fax:217-373-1856
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist