Provider Demographics
NPI:1083636658
Name:WILSON, JOEL R (PHD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:R
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 5TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58401-3437
Mailing Address - Country:US
Mailing Address - Phone:701-253-4000
Mailing Address - Fax:701-253-4040
Practice Address - Street 1:904 5TH AVE NE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-3437
Practice Address - Country:US
Practice Address - Phone:701-253-4000
Practice Address - Fax:701-253-4040
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND322103TP0814X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
Provider Identifiers
StateIdentifier IDID TypeIssuer
N/AMedicare UPIN