Provider Demographics
NPI:1265464242
Name:WILSON, JEFF A (DC)
Entity Type:Individual
Prefix:DR
First Name:JEFF
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 1/2 N PEARL ST
Mailing Address - Street 2:
Mailing Address - City:PAOLA
Mailing Address - State:KS
Mailing Address - Zip Code:66071-1138
Mailing Address - Country:US
Mailing Address - Phone:913-294-9993
Mailing Address - Fax:913-294-9991
Practice Address - Street 1:820 1/2 N PEARL ST
Practice Address - Street 2:
Practice Address - City:PAOLA
Practice Address - State:KS
Practice Address - Zip Code:66071-1138
Practice Address - Country:US
Practice Address - Phone:913-294-9993
Practice Address - Fax:913-294-9991
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS4077111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSU29408Medicare UPIN
KS062004Medicare ID - Type Unspecified