Provider Demographics
NPI:1821464645
Name:WILSON, JEFFERSON
Entity Type:Individual
Prefix:
First Name:JEFFERSON
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 WALNUT ST
Mailing Address - Street 2:SUITE 320L
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5211
Mailing Address - Country:US
Mailing Address - Phone:215-601-8976
Mailing Address - Fax:
Practice Address - Street 1:909 WALNUT ST
Practice Address - Street 2:SUITE 320L
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5211
Practice Address - Country:US
Practice Address - Phone:215-601-8976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-16
Last Update Date:2015-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD454836174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist