Provider Demographics
NPI:1558859256
Name:WILLSON, JONATHAN DANIEL
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DANIEL
Last Name:WILLSON
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 1:207 LUNINBORG ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-8718
Mailing Address - Country:US
Mailing Address - Phone:702-265-4863
Mailing Address - Fax:
Practice Address - Street 1:207 LUNINBORG ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-8718
Practice Address - Country:US
Practice Address - Phone:702-265-4863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-27
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Single Specialty