| Doctor Name: | JACOB W. WILSON |
| NPI Number: | 1114286648 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | LCSW |
| License Number: | LCSW30132 |
| Business Practice Address: | 301 Deinhard Ln Mccall, ID - 836384703 |
| Business Phone Number: | 2086304040 |
| Business Fax Number: | 2086344055 |
| Mailing Address: | Po Box 2553, MCCALL |
| State: | ID |
| Postal Code: | 836382553 |
| Phone Number: | 2086304040 |
| Fax Number: | 2086344055 |
| NPI Enumeration Date: | 05/03/2012 |
| NPI Last Update Date: | 01/18/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | LCSW30132 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | ID |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |