Provider Demographics
NPI:1750656591
Name:WILSON, JENNIFER (CLC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7304 CLANCY WAY
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-9306
Mailing Address - Country:US
Mailing Address - Phone:614-537-8475
Mailing Address - Fax:
Practice Address - Street 1:7304 CLANCY WAY
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-9306
Practice Address - Country:US
Practice Address - Phone:614-537-8475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist