Provider Demographics
NPI:1285230714
Name:WILSON, JUSTIN LEE (DPH)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:LEE
Last Name:WILSON
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2715 JACKSBORO PIKE
Mailing Address - Street 2:
Mailing Address - City:JACKSBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37757-4851
Mailing Address - Country:US
Mailing Address - Phone:423-563-7455
Mailing Address - Fax:423-563-7448
Practice Address - Street 1:2715 JACKSBORO PIKE
Practice Address - Street 2:
Practice Address - City:JACKSBORO
Practice Address - State:TN
Practice Address - Zip Code:37757-4851
Practice Address - Country:US
Practice Address - Phone:423-563-7455
Practice Address - Fax:423-563-7448
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37476183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist