Provider Demographics
NPI:1023429297
Name:WILSON, JANE C
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:C
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 1:3433 LITHIA PINECREST RD STE 135
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33596-6302
Mailing Address - Country:US
Mailing Address - Phone:813-391-8398
Mailing Address - Fax:
Practice Address - Street 1:3433 LITHIA PINECREST RD STE 135
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33596-6302
Practice Address - Country:US
Practice Address - Phone:813-391-8398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-09
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
FLSI18502355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist