Provider Demographics
NPI:1679222392
Name:WILSON, JEDEDIAH HEATH (MED, PLPC)
Entity Type:Individual
Prefix:
First Name:JEDEDIAH
Middle Name:HEATH
Last Name:WILSON
Suffix:
Gender:M
Credentials:MED, PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-1489
Mailing Address - Country:US
Mailing Address - Phone:314-371-6500
Mailing Address - Fax:314-842-2552
Practice Address - Street 1:12141 LADUE RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8120
Practice Address - Country:US
Practice Address - Phone:314-878-4340
Practice Address - Fax:314-842-2552
Is Sole Proprietor?:No
Enumeration Date:2022-03-21
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator