Healthcare Provider Details

I. General information

NPI: 1982141610
Provider Name (Legal Business Name): JEANNIE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2017
Last Update Date: 01/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2285 BENTON RD SUITE D-103
BOSSIER CITY LA
71111-7933
US

IV. Provider business mailing address

2285 BENTON RD SUITE D-103
BOSSIER CITY LA
71111-7933
US

V. Phone/Fax

Practice location:
  • Phone: 318-584-7197
  • Fax: 318-584-7080
Mailing address:
  • Phone: 318-584-7197
  • Fax: 318-584-7080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: