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General NPI Number Information
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NPI Number | 1548827165
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Entity Type | Individual
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Provider Name | JENNA WILSON M.S., CCC-SLP
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Gender | Female
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Dates
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Enumeration Date | 05/20/2019
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Last Update Date | 02/27/2024
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Provider Practice Location Address
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Address Line | 477 PROMINENCE CT STE 100
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City | DAWSONVILLE
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State | GA
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Zip | 30534-6377
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Country | US
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Telephone | 401-216-9564
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Fax |
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Provider Business Mailing Address
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Address Line | 629 STANDING ROCK RD
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City | SENOIA
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State | GA
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Zip | 30276-1405
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Country | US
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Telephone | 404-925-6777
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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 | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | SLP010194
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License Number State | GA
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