Healthcare Provider Details

I. General information

NPI: 1093627614
Provider Name (Legal Business Name): SILECE SHANTALE WILBOURN MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 HIGHWAY 51 N
BATESVILLE MS
38606-2348
US

IV. Provider business mailing address

1867 CRANE RIDGE DR STE 150C
JACKSON MS
39216-4982
US

V. Phone/Fax

Practice location:
  • Phone: 662-712-6257
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: