Provider Demographics
NPI:1760108245
Name:WILSON, JENNIFER MARY (LMFT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARY
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12895 HIGHWAY 9
Mailing Address - Street 2:
Mailing Address - City:BOULDER CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:95006-9114
Mailing Address - Country:US
Mailing Address - Phone:720-297-5023
Mailing Address - Fax:
Practice Address - Street 1:12895 HIGHWAY 9
Practice Address - Street 2:
Practice Address - City:BOULDER CREEK
Practice Address - State:CA
Practice Address - Zip Code:95006-9114
Practice Address - Country:US
Practice Address - Phone:720-297-5023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMFT.0001601101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health