Provider Demographics
NPI:1346795762
Name:WILSON, JENNIFER LYNN (BS, LADC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:BS, LADC
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:STANLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:510 SE 13TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-4233
Mailing Address - Country:US
Mailing Address - Phone:218-327-2570
Mailing Address - Fax:218-326-1036
Practice Address - Street 1:510 SE 13TH ST
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-4233
Practice Address - Country:US
Practice Address - Phone:218-327-2570
Practice Address - Fax:218-326-1036
Is Sole Proprietor?:No
Enumeration Date:2016-08-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304574101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)