Provider Demographics
NPI:1861880106
Name:WILSON, KASEY BROOKE
Entity type:Individual
Prefix:
First Name:KASEY
Middle Name:BROOKE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CLOVERDALE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72076-5614
Mailing Address - Country:US
Mailing Address - Phone:501-982-3117
Mailing Address - Fax:501-241-2004
Practice Address - Street 1:500 CLOVERDALE RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-5614
Practice Address - Country:US
Practice Address - Phone:501-982-3117
Practice Address - Fax:501-241-2004
Is Sole Proprietor?:No
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant