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General NPI Number Information
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NPI Number | 1750437158
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Entity Type | Individual
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Provider Name | JERRY CLYDE WILSON M.S., L.P.C.
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Gender | Male
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Dates
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Enumeration Date | 01/26/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 3516 NE STALLINGS DR
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City | NACOGDOCHES
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State | TX
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Zip | 75965-8732
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Country | US
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Telephone | 936-569-6562
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 630325
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City | NACOGDOCHES
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State | TX
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Zip | 75963-0325
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Country | US
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Telephone | 936-569-6562
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 625
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License Number State | TX
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