Provider Demographics
NPI:1497176903
Name:WILSON, JONATHAN PHILLIP
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:PHILLIP
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 1:20380 SHOSHONEE RD
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-5604
Mailing Address - Country:US
Mailing Address - Phone:760-617-6722
Mailing Address - Fax:
Practice Address - Street 1:20380 SHOSHONEE RD
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-5604
Practice Address - Country:US
Practice Address - Phone:760-617-6722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-31
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA86228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist