Provider Demographics
NPI:1639548910
Name:WILSON, JONATHAN R (AUD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:R
Last Name:WILSON
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 475 BOX 1
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96350-1200
Mailing Address - Country:US
Mailing Address - Phone:315-243-2600
Mailing Address - Fax:
Practice Address - Street 1:PSC 475 BOX 1
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96350-1200
Practice Address - Country:US
Practice Address - Phone:315-243-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-17
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80810237600000X
MO2015039572237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1639548910Medicaid