Provider Demographics
NPI:1396951232
Name:WILSON, MARY JO (RN,,MSN,CS-P)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JO
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN,,MSN,CS-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7257 HANOVER PKWY STE C
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-3612
Mailing Address - Country:US
Mailing Address - Phone:301-474-1679
Mailing Address - Fax:301-231-0716
Practice Address - Street 1:7257 HANOVER PKWY STE C
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-3612
Practice Address - Country:US
Practice Address - Phone:301-474-1679
Practice Address - Fax:301-231-0716
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR034710101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR034710OtherREGISTERED NURSE APRN PMH