Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 104100000X | Social Worker |
NPI | 1003225368 |
---|---|
Provider Name | Mrs. Jessica Ann Wilson |
First Address | Portland, OR 97220-6832 |
Second Address | Portland, OR 97220-6832 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/08/2014 |
Last Update Date | 11/08/2014 |