Provider Demographics
NPI:1386660819
Name:WILSON, JACQUELYNE JONES (MA, LPC)
Entity Type:Individual
Prefix:
First Name:JACQUELYNE
Middle Name:JONES
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA, LPC
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 70651
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-0029
Mailing Address - Country:US
Mailing Address - Phone:843-222-1188
Mailing Address - Fax:
Practice Address - Street 1:4705 OLEANDER DR
Practice Address - Street 2:MYRTLE BEACH
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5751
Practice Address - Country:US
Practice Address - Phone:843-222-1188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor