Provider Demographics
NPI:1255849626
Name:WILSON, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 945E ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT STERLING
Mailing Address - State:IL
Mailing Address - Zip Code:62353-4410
Mailing Address - Country:US
Mailing Address - Phone:217-257-0369
Mailing Address - Fax:
Practice Address - Street 1:2000 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IA
Practice Address - Zip Code:52556-9572
Practice Address - Country:US
Practice Address - Phone:641-472-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-18
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60960737225100000X
IA090148225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist