Healthcare Provider Details

I. General information

NPI: 1063643567
Provider Name (Legal Business Name): WILSON CLINICAL SERVICES, PLLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2009
Last Update Date: 02/09/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1117 A ST
TACOMA WA
98402-5003
US

IV. Provider business mailing address

1117 A ST
TACOMA WA
98402-5003
US

V. Phone/Fax

Practice location:
  • Phone: 360-339-7752
  • Fax:
Mailing address:
  • Phone: 360-339-7752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number602937457
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. JAIME A B WILSON
Title or Position: PRESCRIBING MEDICAL PSYCHOLOGIST
Credential: PH.D., ABPP, MSCP
Phone: 253-200-0255