Provider Demographics
NPI:1598210171
Name:PAO WILSON, JEAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:
Last Name:PAO 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 1:117 PARK AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089-3371
Mailing Address - Country:US
Mailing Address - Phone:413-732-7677
Mailing Address - Fax:413-732-7688
Practice Address - Street 1:117 PARK AVE STE 205
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-3371
Practice Address - Country:US
Practice Address - Phone:413-732-7677
Practice Address - Fax:413-732-7688
Is Sole Proprietor?:No
Enumeration Date:2016-08-24
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7891103TC0700X, 103TC2200X, 103TF0000X, 103TH0004X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth