Provider Demographics
NPI:1942452016
Name:WILSON, JIL
Entity Type:Individual
Prefix:
First Name:JIL
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2008 N VAGEDES AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93705-5147
Mailing Address - Country:US
Mailing Address - Phone:559-593-9673
Mailing Address - Fax:
Practice Address - Street 1:3467 W SHAW AVE
Practice Address - Street 2:SUITE #102
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3223
Practice Address - Country:US
Practice Address - Phone:559-274-0456
Practice Address - Fax:559-274-0292
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CAW0811071114101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)