Provider Demographics
NPI:1366831117
Name:WILSON, JED (LICSW)
Entity Type:Individual
Prefix:
First Name:JED
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 111
Mailing Address - Street 2:
Mailing Address - City:CENTER CONWAY
Mailing Address - State:NH
Mailing Address - Zip Code:03813-0111
Mailing Address - Country:US
Mailing Address - Phone:603-730-9154
Mailing Address - Fax:603-730-9154
Practice Address - Street 1:90 ODELL HILL RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03818-4401
Practice Address - Country:US
Practice Address - Phone:603-730-9154
Practice Address - Fax:603-730-9154
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-16
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH20211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical