Provider Demographics
NPI:1942912217
Name:WILSON, JESSICA (MA, ALC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA, ALC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 SOUTHVIEW LN STE 103-254
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35405-6390
Mailing Address - Country:US
Mailing Address - Phone:205-722-7294
Mailing Address - Fax:
Practice Address - Street 1:3802 OFC. TREVOR S. PHILLIPS AVE
Practice Address - Street 2:SUITE A
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401
Practice Address - Country:US
Practice Address - Phone:205-722-7294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALALC03973101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE