Provider Demographics
NPI:1255344396
Name:WILSON, JAMES DOUGLAS (LCSW)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:DOUGLAS
Last Name:WILSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9054
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-9054
Mailing Address - Country:US
Mailing Address - Phone:423-467-3600
Mailing Address - Fax:423-467-3696
Practice Address - Street 1:607 BAXTER ST
Practice Address - Street 2:FAIRVIEW ASSOCIATES
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601
Practice Address - Country:US
Practice Address - Phone:423-232-2720
Practice Address - Fax:423-928-0381
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLCSW709104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
0128301OtherMAGELLAN NAVIGATOR
189387 FVJCOtherANTHEM PROF TRIGON
33476OtherUBH EMPLOYER
334969OtherVALUEOPTIONS GROUP
0128301OtherMAGELLAN SUMMIT
0128301OtherMAGELLAN EAP
1046524OtherFIRST HEALTH
0128301OtherMAGELLAN PINNACLE
104224OtherVALUEOPTIONS
55538OtherCIGNA MCC
189387 FVJCOtherANTHEM PREF TRIGON
33476OtherUBH HEALTHPLAN
33476OtherUBH SENIOR
189387 FVJCOtherANTHEM PREF TRIGON
33476OtherUBH EMPLOYER