Provider Demographics
NPI:1437505021
Name:WILSON, JACQUELIN (LPC)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELIN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 PIERCE AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-2860
Mailing Address - Country:US
Mailing Address - Phone:478-475-4608
Mailing Address - Fax:478-476-8397
Practice Address - Street 1:144 PIERCE AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-2860
Practice Address - Country:US
Practice Address - Phone:478-475-4608
Practice Address - Fax:478-476-8397
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-12
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008703101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional