Provider Demographics
NPI:1124242680
Name:WILSON, JILL (LPC)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 DULUTH PARK LN
Mailing Address - Street 2:SUITE 410
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-3242
Mailing Address - Country:US
Mailing Address - Phone:770-418-1078
Mailing Address - Fax:
Practice Address - Street 1:3500 DULUTH PARK LN
Practice Address - Street 2:SUITE 410
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-3242
Practice Address - Country:US
Practice Address - Phone:770-418-1078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001627101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional