Provider Demographics
NPI:1386696623
Name:WILSON, J PATRICK (MA LMFT LPC-S)
Entity type:Individual
Prefix:MR
First Name:J
Middle Name:PATRICK
Last Name:WILSON
Suffix:
Gender:M
Credentials:MA LMFT LPC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 53527
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-3527
Mailing Address - Country:US
Mailing Address - Phone:337-233-1775
Mailing Address - Fax:337-233-1775
Practice Address - Street 1:322 HEYMANN BLVD
Practice Address - Street 2:BLDG. B, STE. 4
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2465
Practice Address - Country:US
Practice Address - Phone:337-233-1775
Practice Address - Fax:337-233-1775
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA8106H00000X
LA2653101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist