Basic Information
| Provider Information | |||||||||
| NPI: | 1750667804 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | KATHLEEN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW-CC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 72 WINTHROP ST | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043305500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076263455 | ||||||||
| FaxNumber: | 2076267586 | ||||||||
| Practice Location | |||||||||
| Address1: | 72 WINTHROP ST | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043305500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076263455 | ||||||||
| FaxNumber: | 2076267586 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2011 | ||||||||
| LastUpdateDate: | 11/10/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | MC13106 | ME | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.