Provider Demographics
NPI:1679222392
Name:WILSON, JEDEDIAH HEATH (MED, LPC, NCC)
Entity type:Individual
Prefix:
First Name:JEDEDIAH
Middle Name:HEATH
Last Name:WILSON
Suffix:
Gender:M
Credentials:MED, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6705 PARKWOOD PL
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-2153
Mailing Address - Country:US
Mailing Address - Phone:312-513-0239
Mailing Address - Fax:
Practice Address - Street 1:5501 DELMAR BLVD STE B300
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-3078
Practice Address - Country:US
Practice Address - Phone:314-469-4908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-21
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 1041C0700X, 171M00000X, 101YP2500X
MO2022014908101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator