Provider Demographics
NPI:1841771144
Name:WILSON, JERI ELLEN (LCSW)
Entity Type:Individual
Prefix:
First Name:JERI
Middle Name:ELLEN
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW
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 710733
Mailing Address - Street 2:
Mailing Address - City:SANTEE
Mailing Address - State:CA
Mailing Address - Zip Code:92072-0733
Mailing Address - Country:US
Mailing Address - Phone:619-436-1343
Mailing Address - Fax:619-764-4020
Practice Address - Street 1:8885 RIO SAN DIEGO DR STE 237
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1661
Practice Address - Country:US
Practice Address - Phone:619-922-1815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-24
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW746081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA38-4020631OtherDEPARTMENT OF TREASURY