Provider Demographics
NPI:1487001509
Name:WILSON, JODI ELIZABETH (DC)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:ELIZABETH
Last Name:WILSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 SUGAR CREEK CENTER BLVD
Mailing Address - Street 2:STE. 100
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478-4064
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:54 SUGAR CREEK CENTER BLVD
Practice Address - Street 2:STE. 100
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-4064
Practice Address - Country:US
Practice Address - Phone:281-494-1690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-18
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13211111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX561911ZZC7Medicare PIN
TX561911ZH7TMedicare PIN