Healthcare Provider Details

I. General information

NPI: 1669061446
Provider Name (Legal Business Name): JESSICA WILSON LPC/MHSP, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2021
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 S MAIN ST UNIT 105
SPRINGFIELD TN
37172-2809
US

IV. Provider business mailing address

719 S MAIN ST UNIT 105
SPRINGFIELD TN
37172-2809
US

V. Phone/Fax

Practice location:
  • Phone: 615-504-3349
  • Fax:
Mailing address:
  • Phone: 615-504-3349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number28314
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6175
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6175
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: