Provider Demographics
NPI:1558707539
Name:WILSON, JOHN WESLEY (PC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WESLEY
Last Name:WILSON
Suffix:
Gender:M
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 E PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45506-2201
Mailing Address - Country:US
Mailing Address - Phone:937-325-5564
Mailing Address - Fax:937-325-8727
Practice Address - Street 1:701 E COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-4404
Practice Address - Country:US
Practice Address - Phone:937-325-5564
Practice Address - Fax:937-325-8727
Is Sole Proprietor?:No
Enumeration Date:2013-05-16
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC1100342101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional