Provider Demographics
NPI:1508192352
Name:WILSON, JOHNNY
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
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 1:925 CALHOUN AVE
Mailing Address - Street 2:
Mailing Address - City:YAZOO CITY
Mailing Address - State:MS
Mailing Address - Zip Code:39194-3229
Mailing Address - Country:US
Mailing Address - Phone:662-746-7770
Mailing Address - Fax:662-746-4185
Practice Address - Street 1:925 CALHOUN AVE
Practice Address - Street 2:
Practice Address - City:YAZOO CITY
Practice Address - State:MS
Practice Address - Zip Code:39194-3229
Practice Address - Country:US
Practice Address - Phone:662-746-7770
Practice Address - Fax:662-746-4185
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-29
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT1629225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist