Healthcare Provider Details

I. General information

NPI: 1639948334
Provider Name (Legal Business Name): JASON PAUL WILSON LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2023
Last Update Date: 12/22/2023
Certification Date: 12/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 HILLCREST DR STE 8
WACO TX
76708-3144
US

IV. Provider business mailing address

2290 WOLF LN
VALLEY MILLS TX
76689-2834
US

V. Phone/Fax

Practice location:
  • Phone: 254-262-3506
  • Fax: 254-262-3506
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number204966
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: