Provider Demographics
NPI:1598001851
Name:WILSON, JENNIFER CRISTINA
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CRISTINA
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 1:16306 SW 103RD ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-5874
Mailing Address - Country:US
Mailing Address - Phone:786-514-4027
Mailing Address - Fax:
Practice Address - Street 1:16306 SW 103RD ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196-5874
Practice Address - Country:US
Practice Address - Phone:786-514-4027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-13
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst