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General NPI Number Information
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NPI Number | 1164630018
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Entity Type | Individual
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Provider Name | EARL WILSON III REV, LMFT
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Gender | Male
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Dates
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Enumeration Date | 05/21/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 6205 HANGING MOSS RD
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City | JACKSON
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State | MS
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Zip | 39206-2121
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Country | US
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Telephone | 601-982-3997
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Fax | 601-982-8933
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Provider Business Mailing Address
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Address Line | 706 COLONIAL CIR
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City | JACKSON
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State | MS
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Zip | 39211-3208
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Country | US
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Telephone | 601-899-5827
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 35001450
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License Number State | IN
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