Provider Demographics
NPI:1528451333
Name:WILSON, JENNIFER LEIGHS (PHD, LCSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEIGHS
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 HIGH TIDE DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-2323
Mailing Address - Country:US
Mailing Address - Phone:904-342-8261
Mailing Address - Fax:
Practice Address - Street 1:141 WHISPERING OAKS CIR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-1703
Practice Address - Country:US
Practice Address - Phone:561-701-4984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-18
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW84311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical