Provider Demographics
NPI:1497894836
Name:WILSON, JENNIFER L (PHD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 MERTON MINTER BOULEVARD
Mailing Address - Street 2:STVHCS - AUDIE L. MURPHY MEMORIAL VETERANS HOSPITAL
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4404
Mailing Address - Country:US
Mailing Address - Phone:210-617-5121
Mailing Address - Fax:
Practice Address - Street 1:7400 MERTON MINTER BOULEVARD
Practice Address - Street 2:STVHCS - AUDIE L. MURPHY MEMORIAL VETERANS HOSPITAL
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4404
Practice Address - Country:US
Practice Address - Phone:210-617-5121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6944103TB0200X, 103TC1900X, 103TC2200X, 103TF0000X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation