Provider Demographics
NPI:1114190576
Name:WILSON, JAMIE JOHNSTON (PTA)
Entity Type:Individual
Prefix:MR
First Name:JAMIE
Middle Name:JOHNSTON
Last Name:WILSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13295 COUNTY ROAD 5480
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-5873
Mailing Address - Country:US
Mailing Address - Phone:573-368-2644
Mailing Address - Fax:
Practice Address - Street 1:HWY 72 WEST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MO
Practice Address - Zip Code:65560
Practice Address - Country:US
Practice Address - Phone:573-729-6141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007017529163W00000X
MO2007023425225200000X
IL163W00000X, 225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No163W00000XNursing Service ProvidersRegistered Nurse