Healthcare Provider Details

I. General information

NPI: 1528451333
Provider Name (Legal Business Name): JENNIFER LEIGHS WILSON PHD, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2015
Last Update Date: 03/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 WHISPERING OAKS CIR
ST AUGUSTINE FL
32080-1703
US

IV. Provider business mailing address

320 HIGH TIDE DR
ST AUGUSTINE FL
32080-2323
US

V. Phone/Fax

Practice location:
  • Phone: 561-701-4984
  • Fax:
Mailing address:
  • Phone: 904-342-8261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW8431
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: