Provider Demographics
NPI:1285043968
Name:WILSON, SHANDRA (LPC)
Entity type:Individual
Prefix:
First Name:SHANDRA
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 1:610 E LEAKE ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-4321
Mailing Address - Country:US
Mailing Address - Phone:337-764-2065
Mailing Address - Fax:
Practice Address - Street 1:4500 I 55 N STE 223
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5931
Practice Address - Country:US
Practice Address - Phone:337-764-2065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-07
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70098101YP2500X
LA4151101YP2500X
MS1835101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional