Provider Demographics
NPI:1962022178
Name:WILSON, JENNIFER MEGAN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MEGAN
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 1:807 SAM CHRISTOPHER CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-3048
Mailing Address - Country:US
Mailing Address - Phone:606-273-7510
Mailing Address - Fax:
Practice Address - Street 1:332 HIGHLAND PARK DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-3487
Practice Address - Country:US
Practice Address - Phone:859-913-1315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-17
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY242479101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health