Individual
KELLY L WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
200 N CONGRESS ST, SUITE 100, JACKSON, MS 39201-1902
(601) 355-8634
Mailing address
200 N CONGRESS ST, SUITE 100, JACKSON, MS 39201-1902
(601) 355-8634
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
Primary
C5370
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
08135705
—
MS
Enumeration date
01/23/2007
Last updated
09/23/2007
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