Provider Demographics
NPI:1811015092
Name:WILSON, JEFFREY JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:JOHN
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2017 JEFFERSON ST SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-2419
Mailing Address - Country:US
Mailing Address - Phone:540-853-0900
Mailing Address - Fax:540-853-0518
Practice Address - Street 1:2017 JEFFERSON ST SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-2419
Practice Address - Country:US
Practice Address - Phone:540-853-0900
Practice Address - Fax:540-853-0518
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2014-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT82250572084P0804X, 2084P0802X, 2084P0800X
VA0101-2561872084P0800X, 2084P0804X, 2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVD703AOtherMEDICARE PTAN
H32968Medicare UPIN