Provider Demographics
NPI:1689847386
Name:WILSON, JAMES VERNON (MA, LISAC)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:VERNON
Last Name:WILSON
Suffix:
Gender:M
Credentials:MA, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2123 W CHAMBERS ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-3720
Mailing Address - Country:US
Mailing Address - Phone:602-276-5653
Mailing Address - Fax:
Practice Address - Street 1:2123 W CHAMBERS ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-3720
Practice Address - Country:US
Practice Address - Phone:602-276-5653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-02
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11800101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)