Provider Demographics
NPI:1396148623
Name:WILSON, FRED SR
Entity type:Individual
Prefix:MR
First Name:FRED
Middle Name:
Last Name:WILSON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 N LIBERTY ST
Mailing Address - Street 2:APT B219
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32206-5676
Mailing Address - Country:US
Mailing Address - Phone:904-238-1240
Mailing Address - Fax:904-358-1551
Practice Address - Street 1:945 N LIBERTY ST
Practice Address - Street 2:APT B219
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206-5676
Practice Address - Country:US
Practice Address - Phone:904-238-1240
Practice Address - Fax:904-358-1551
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-01
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health