MEDICARE: MR. HENRY A WILSON JR. MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor

General Provider Information

NPI Number	:	1013123785
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. HENRY A WILSON JR. MS

Provider Business Mailing Address
First Line	:	32258 BASILHAM LN
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-4444
Country	:	US
Telephone Number	:	413-557-8344
Fax Number	:

Provider Business Practice Location Address
First Line	:	4720 SALISBURY RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-6101
Country	:	US
Telephone Number	:	904-608-9881
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	11/19/2014

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