Provider Demographics
NPI:1689785388
Name:WILSON, JAYE STANSBURY (MA, CCC)
Entity Type:Individual
Prefix:MS
First Name:JAYE
Middle Name:STANSBURY
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA, CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 901
Mailing Address - Street 2:
Mailing Address - City:PILOT MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:27041-0901
Mailing Address - Country:US
Mailing Address - Phone:336-786-1210
Mailing Address - Fax:336-786-1408
Practice Address - Street 1:535 E PINE ST
Practice Address - Street 2:RIVERSIDE PROFESSIONAL OFFICES, SUITE 211
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-3951
Practice Address - Country:US
Practice Address - Phone:336-786-1210
Practice Address - Fax:336-786-1408
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1112235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC88341OtherBLUE CROSS BLUE SHIELD
NC7210340Medicaid