Provider Demographics
NPI:1093955775
Name:WILSON, JOHN ROOSEVELT (LISW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ROOSEVELT
Last Name:WILSON
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 WIND RUSH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-4439
Mailing Address - Country:US
Mailing Address - Phone:614-986-8911
Mailing Address - Fax:
Practice Address - Street 1:1955 OHIO DR
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-4835
Practice Address - Country:US
Practice Address - Phone:614-257-5800
Practice Address - Fax:614-257-5801
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-20
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI06001631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical