Provider Demographics
NPI:1922648674
Name:WILSON, JEROME
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JEROME
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:100 DIPLOMAT WAY
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-4314
Mailing Address - Country:US
Mailing Address - Phone:985-316-6483
Mailing Address - Fax:
Practice Address - Street 1:100 DIPLOMAT WAY
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4314
Practice Address - Country:US
Practice Address - Phone:985-316-6483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA38-3949990103TF0000X
LA103TF0000X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LANAMedicaid