Provider Demographics
NPI:1215414248
Name:WILSON, JONATHAN (LMSW)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 WHITE PLAINS RD STE 510
Mailing Address - Street 2:
Mailing Address - City:TARRYTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10591-5152
Mailing Address - Country:US
Mailing Address - Phone:914-345-5900
Mailing Address - Fax:
Practice Address - Street 1:29 STERLING AVE
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10606-3001
Practice Address - Country:US
Practice Address - Phone:914-949-1212
Practice Address - Fax:914-949-5802
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103482104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker