Provider Demographics
NPI:1396637179
Name:WILSON BERNSTINE, JESSICA NICOLE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:WILSON BERNSTINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4819 SHIMMER SIDE DR
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77493-5529
Mailing Address - Country:US
Mailing Address - Phone:228-623-8702
Mailing Address - Fax:
Practice Address - Street 1:2021 GUADALUPE ST STE 260
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-5654
Practice Address - Country:US
Practice Address - Phone:646-941-7645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-16
Last Update Date:2025-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX92053101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health