Healthcare Provider Details

I. General information

NPI: 1326819590
Provider Name (Legal Business Name): JACQUELYN WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2024
Last Update Date: 01/15/2024
Certification Date: 01/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 YORK RD STE 216
TIMONIUM MD
21093-2276
US

IV. Provider business mailing address

221 LUBERTHA RD
RIDGELAND MS
39157-5070
US

V. Phone/Fax

Practice location:
  • Phone: 443-202-7736
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberM9984
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number31047
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: