Provider Demographics
NPI:1679840227
Name:WILSON, JONATHAN B (MS, LMFTA)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:B
Last Name:WILSON
Suffix:
Gender:M
Credentials:MS, LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-3411
Mailing Address - Country:US
Mailing Address - Phone:252-737-1415
Mailing Address - Fax:
Practice Address - Street 1:612 E 10TH ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-3411
Practice Address - Country:US
Practice Address - Phone:252-737-1415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7089A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist