Provider Demographics
NPI:1598906935
Name:WILSON, JEFF RANDALL
Entity Type:Individual
Prefix:DR
First Name:JEFF
Middle Name:RANDALL
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 1:141 W 46TH AVE
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46408-3905
Mailing Address - Country:US
Mailing Address - Phone:219-614-0793
Mailing Address - Fax:
Practice Address - Street 1:141 W 46TH AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46408-3905
Practice Address - Country:US
Practice Address - Phone:219-614-0793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-16
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral