Provider Demographics
NPI:1942373212
Name:WILSON, JACQUELINE (MED LMHC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MED LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 SUMMER ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-4173
Mailing Address - Country:US
Mailing Address - Phone:508-740-4316
Mailing Address - Fax:
Practice Address - Street 1:6 CABOT PL STE 6
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:MA
Practice Address - Zip Code:02072-4625
Practice Address - Country:US
Practice Address - Phone:508-740-4316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health