Provider Demographics
NPI:1053638049
Name:JAY WILSON D.C. P.C.
Entity Type:Organization
Organization Name:JAY WILSON D.C. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:303-449-7414
Mailing Address - Street 1:1455 YARMOUTH AVE STE 112
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-4345
Mailing Address - Country:US
Mailing Address - Phone:303-449-7414
Mailing Address - Fax:303-449-2147
Practice Address - Street 1:1455 YARMOUTH AVE STE 112
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-4345
Practice Address - Country:US
Practice Address - Phone:303-449-7414
Practice Address - Fax:303-449-2147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-29
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2311302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization