Healthcare Provider Details

I. General information

NPI: 1316244247
Provider Name (Legal Business Name): JAMESIA WILSON LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2011
Last Update Date: 02/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 HIGHWAY 80 W
JACKSON MS
39209-7201
US

IV. Provider business mailing address

3450 HIGHWAY 80 W
JACKSON MS
39209-7201
US

V. Phone/Fax

Practice location:
  • Phone: 601-321-2400
  • Fax: 601-321-2476
Mailing address:
  • Phone: 601-321-2400
  • Fax: 601-321-2476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberW7331
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: