Provider Demographics
NPI:1679297816
Name:WILSON, JOHN BRYAN (QHMP)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BRYAN
Last Name:WILSON
Suffix:
Gender:M
Credentials:QHMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20370 POE SHOLES DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-7938
Mailing Address - Country:US
Mailing Address - Phone:541-318-1377
Mailing Address - Fax:
Practice Address - Street 1:20370 POE SHOLES DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-7938
Practice Address - Country:US
Practice Address - Phone:541-318-1377
Practice Address - Fax:541-383-4587
Is Sole Proprietor?:No
Enumeration Date:2022-09-30
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22-QHMP-R-1539101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health