Provider Demographics
NPI:1821012808
Name:WILSON, JODI ELAINE (MA)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:ELAINE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 N ROAD 60
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-2175
Mailing Address - Country:US
Mailing Address - Phone:509-688-7967
Mailing Address - Fax:509-380-5072
Practice Address - Street 1:719 JADWIN AVE
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-4217
Practice Address - Country:US
Practice Address - Phone:509-688-7967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60049887101YM0800X
MO2004014916101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional