Provider Demographics
NPI:1417111329
Name:WILSON, JON MICHAEL (MA CCC-A)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:MICHAEL
Last Name:WILSON
Suffix:
Gender:M
Credentials:MA CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7375 W 52ND AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80002-3748
Mailing Address - Country:US
Mailing Address - Phone:303-953-5976
Mailing Address - Fax:303-424-0281
Practice Address - Street 1:7375 W 52ND AVE STE 310
Practice Address - Street 2:
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80002-3748
Practice Address - Country:US
Practice Address - Phone:303-953-5976
Practice Address - Fax:303-424-0281
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO407231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist