Basic Information
| Provider Information | |||||||||
| NPI: | 1528579414 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JEREESE | ||||||||
| MiddleName: | |||||||||
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| Credential: | MSW, LSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BARRETT | ||||||||
| OtherFirstName: | JEREESE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 118 W PROSPECT ST | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449071230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196109383 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 680 PARK AVE W | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449063706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195285993 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2017 | ||||||||
| LastUpdateDate: | 07/26/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | S1500492 | OH | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | LICDC.162049 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.