Healthcare Provider Details

I. General information

NPI: 1679222392
Provider Name (Legal Business Name): JEDEDIAH HEATH WILSON MED, LPC, NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2022
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 DELMAR BLVD STE B300
SAINT LOUIS MO
63112-3078
US

IV. Provider business mailing address

6705 PARKWOOD PL
SAINT LOUIS MO
63116-2153
US

V. Phone/Fax

Practice location:
  • Phone: 314-469-4908
  • Fax:
Mailing address:
  • Phone: 312-513-0239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number2022014908
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: