Provider Demographics
NPI:1609165224
Name:WILCOX, JERRAME MAX (LAC)
Entity Type:Individual
Prefix:MR
First Name:JERRAME
Middle Name:MAX
Last Name:WILCOX
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:MR
Other - First Name:MAX
Other - Middle Name:
Other - Last Name:WILCOX
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC
Mailing Address - Street 1:2655 CAMINO DEL RIO N
Mailing Address - Street 2:STE. 340
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-1633
Mailing Address - Country:US
Mailing Address - Phone:619-261-8861
Mailing Address - Fax:
Practice Address - Street 1:2655 CAMINO DEL RIO N
Practice Address - Street 2:STE. 340
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1633
Practice Address - Country:US
Practice Address - Phone:619-261-8861
Practice Address - Fax:619-330-9651
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-04
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC13885171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist