Provider Demographics
NPI:1720505274
Name:WILSON, JEFFREY L (MA, LPC, NCC)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:L
Last Name:WILSON
Suffix:
Gender:M
Credentials:MA, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14201 S MUR LEN RD STE 101
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66062-1859
Mailing Address - Country:US
Mailing Address - Phone:913-486-5147
Mailing Address - Fax:
Practice Address - Street 1:14201 S MUR LEN RD STE 101
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66062-1859
Practice Address - Country:US
Practice Address - Phone:913-486-5147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS3094101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health