Provider Demographics
NPI:1316223431
Name:WILSON, JEFFERY ALLAN
Entity Type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:ALLAN
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 1:1702 S NOGALES AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74107-1834
Mailing Address - Country:US
Mailing Address - Phone:918-798-2162
Mailing Address - Fax:
Practice Address - Street 1:1702 S NOGALES AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74107-1834
Practice Address - Country:US
Practice Address - Phone:918-798-2162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health