Basic Information
| Provider Information | |||||||||
| NPI: | 1154641033 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MS, CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 LOWRY LN | ||||||||
| Address2: | |||||||||
| City: | RUTLAND | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015432057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7745353484 | ||||||||
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| Practice Location | |||||||||
| Address1: | 335 CHANDLER ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016023441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087532967 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2010 | ||||||||
| LastUpdateDate: | 07/12/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 5403 | MA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.