Provider Demographics
NPI:1063464832
Name:WILSON, JEFFREY DAVID (MPT)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:DAVID
Last Name:WILSON
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 AGNUS DR
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-1001
Mailing Address - Country:US
Mailing Address - Phone:805-535-4400
Mailing Address - Fax:805-535-4401
Practice Address - Street 1:4080 LOMA VISTA RD
Practice Address - Street 2:SUITE H
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-1811
Practice Address - Country:US
Practice Address - Phone:805-535-4400
Practice Address - Fax:805-535-4401
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT21563225100000X
2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WPT21563AMedicare ID - Type Unspecified
P20783Medicare UPIN