Provider Demographics
NPI:1497874333
Name:WILSON, JASON JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:JOHN
Last Name:WILSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2353 RICE ST STE 225
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-3739
Mailing Address - Country:US
Mailing Address - Phone:651-288-3098
Mailing Address - Fax:651-288-3781
Practice Address - Street 1:2353 RICE ST STE 225
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-3739
Practice Address - Country:US
Practice Address - Phone:651-288-3098
Practice Address - Fax:651-288-3781
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3525111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU69139Medicare UPIN