Provider Demographics
NPI:1417131780
Name:WILSON, JEAN RACHAEL
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:RACHAEL
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 BATH ST APT 5
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93101-2965
Mailing Address - Country:US
Mailing Address - Phone:805-563-0074
Mailing Address - Fax:
Practice Address - Street 1:1515 BATH ST
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93101-3024
Practice Address - Country:US
Practice Address - Phone:805-564-8701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-21
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility