Provider Demographics
NPI:1447443668
Name:KEN WILSON
Entity type:Organization
Organization Name:KEN WILSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:WILSON
Authorized Official - Last Name:EPPS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:706-667-2353
Mailing Address - Street 1:2610 COMMONS BLVD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-2080
Mailing Address - Country:US
Mailing Address - Phone:706-667-2353
Mailing Address - Fax:706-667-2303
Practice Address - Street 1:2610 COMMONS BLVD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-2080
Practice Address - Country:US
Practice Address - Phone:706-667-2353
Practice Address - Fax:706-667-2303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management