Provider Demographics
NPI:1780094094
Name:WILSON, JENNIFER (LCAT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 W 26TH ST
Mailing Address - Street 2:SUITE 309
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-5517
Mailing Address - Country:US
Mailing Address - Phone:917-864-6811
Mailing Address - Fax:
Practice Address - Street 1:526 W 26TH ST
Practice Address - Street 2:SUITE 309
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-5517
Practice Address - Country:US
Practice Address - Phone:917-864-6811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-08
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000882221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist