=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508110917
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILSON-SIGREST, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2012
-----------------------------------------------------
Last Update Date | 11/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 357 TOWNE CENTER BLVD. SUITE 203
-----------------------------------------------------
City | RIDGELAND
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-398-5436
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 HILLCREST DR
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39056-4309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-398-5436
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER MANAGER
-----------------------------------------------------
Name | JENNIFER SIGREST
-----------------------------------------------------
Credential | MS
-----------------------------------------------------
Telephone | 601-398-5436
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC 0557
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | C5370
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------