Provider Demographics
NPI:1346898111
Name:WILSON, JORDAN R (LICSW)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:R
Last Name:WILSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:
Other - Last Name:NEJAIME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1340 BOYLSTON ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-4302
Mailing Address - Country:US
Mailing Address - Phone:617-247-7555
Mailing Address - Fax:617-262-0872
Practice Address - Street 1:1340 BOYLSTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-4302
Practice Address - Country:US
Practice Address - Phone:617-247-7555
Practice Address - Fax:617-262-0872
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1225411041C0700X
AZLCSW-180061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical