Provider Demographics
NPI:1598269680
Name:WILCOCK, JONATHAN NEPHI
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:NEPHI
Last Name:WILCOCK
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 1:1215 LEE ST BOX 800904
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22908-0816
Mailing Address - Country:US
Mailing Address - Phone:434-924-1946
Mailing Address - Fax:434-924-9492
Practice Address - Street 1:1215 LEE ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-0001
Practice Address - Country:US
Practice Address - Phone:434-924-1946
Practice Address - Fax:434-924-9492
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN71381207ZP0105X
VA0116037559390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine