Provider Demographics
NPI:1750667804
Name:WILSON, JACQUELINE KATHLEEN (LMSW-CC)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:KATHLEEN
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMSW-CC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 WINTHROP ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-5500
Mailing Address - Country:US
Mailing Address - Phone:207-626-3455
Mailing Address - Fax:207-626-7586
Practice Address - Street 1:72 WINTHROP ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-5500
Practice Address - Country:US
Practice Address - Phone:207-626-3455
Practice Address - Fax:207-626-7586
Is Sole Proprietor?:No
Enumeration Date:2011-11-02
Last Update Date:2013-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC131061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical