Provider Demographics
NPI:1952676983
Name:WILSON, JESSICA A (MA/LADC-MH)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA/LADC-MH
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:A
Other - Last Name:CRISE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA/LADC-MH CANDIDATE
Mailing Address - Street 1:12444 NW 10TH ST STE 202
Mailing Address - Street 2:#157
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-5845
Mailing Address - Country:US
Mailing Address - Phone:405-265-9047
Mailing Address - Fax:405-265-9049
Practice Address - Street 1:3000 UNITED FOUNDERS BLVD STE 239
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4294
Practice Address - Country:US
Practice Address - Phone:405-265-9047
Practice Address - Fax:405-265-9049
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1321101YM0800X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1321OtherLADC LICENSE