Provider Demographics
NPI:1194568154
Name:WILSON, JAQULYN LEE LUCILLE (LMSW)
Entity type:Individual
Prefix:
First Name:JAQULYN
Middle Name:LEE LUCILLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 688
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:KS
Mailing Address - Zip Code:67301-0688
Mailing Address - Country:US
Mailing Address - Phone:620-331-1748
Mailing Address - Fax:
Practice Address - Street 1:3354 HIGHWAY 160
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:KS
Practice Address - Zip Code:67301-7841
Practice Address - Country:US
Practice Address - Phone:620-331-1748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSPENDING104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker