Provider Demographics
NPI:1811363575
Name:WILSON, JONATHAN B (DPT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:B
Last Name:WILSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10323 MISSION CRK
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-1623
Mailing Address - Country:US
Mailing Address - Phone:251-458-4199
Mailing Address - Fax:
Practice Address - Street 1:3551 ROGER BROOKE DR.
Practice Address - Street 2:
Practice Address - City:JBSA FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-916-7366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-18
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH7703225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL511-68556OtherBCBS OF AL
ALP01586197OtherMEDICARE RR
AL13765704OtherCAQH
AL511-68569OtherBCBS OF AL
AL102I655581Medicare PIN