Provider Demographics
NPI:1063882645
Name:WISDOM, JESSICA (LPC U/S)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:WISDOM
Suffix:
Gender:F
Credentials:LPC U/S
Other - Prefix:MRS
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:GALLION
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC U/S
Mailing Address - Street 1:3016 BRETFORD WAY
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-1872
Mailing Address - Country:US
Mailing Address - Phone:405-421-4849
Mailing Address - Fax:
Practice Address - Street 1:900 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-5305
Practice Address - Country:US
Practice Address - Phone:405-573-6633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-25
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health