Provider Demographics
NPI:1457909830
Name:WILSON, JACQUELINE LOIS REAGOR (MSP, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:LOIS REAGOR
Last Name:WILSON
Suffix:
Gender:F
Credentials:MSP, CCC-SLP
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:LOIS
Other - Last Name:REAGOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1444 HERMITAGE LN
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-3059
Mailing Address - Country:US
Mailing Address - Phone:843-754-5795
Mailing Address - Fax:
Practice Address - Street 1:9285 MEDICAL PLAZA DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9126
Practice Address - Country:US
Practice Address - Phone:843-797-8282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7020235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist