Provider Demographics
NPI:1740846039
Name:WILSON, JACQUELINE HOLLEY
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:HOLLEY
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 1:3644 BUTTERCUP CT
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-1983
Mailing Address - Country:US
Mailing Address - Phone:678-602-9229
Mailing Address - Fax:770-995-1959
Practice Address - Street 1:4305 S LEE ST STE 500
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-5785
Practice Address - Country:US
Practice Address - Phone:678-602-9229
Practice Address - Fax:770-995-1959
Is Sole Proprietor?:No
Enumeration Date:2019-05-13
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAMSW008859OtherLICENSE