Provider Demographics
NPI:1215780598
Name:WILSON, JESSICA FAYE (AMFT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:FAYE
Last Name:WILSON
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16861 PLACER OAKS RD
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-3445
Mailing Address - Country:US
Mailing Address - Phone:650-814-9819
Mailing Address - Fax:
Practice Address - Street 1:127 JEWELL ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-1717
Practice Address - Country:US
Practice Address - Phone:650-814-9819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA145995101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health