Provider Demographics
NPI:1851453344
Name:WILSON, JERROD PRESCOT (DC)
Entity Type:Individual
Prefix:
First Name:JERROD
Middle Name:PRESCOT
Last Name:WILSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12720 S ORANGE BLOSSOM TRL
Mailing Address - Street 2:# 20
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-6225
Mailing Address - Country:US
Mailing Address - Phone:407-438-4888
Mailing Address - Fax:407-398-0117
Practice Address - Street 1:12720 S ORANGE BLOSSOM TRL
Practice Address - Street 2:# 20
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-6225
Practice Address - Country:US
Practice Address - Phone:407-438-4888
Practice Address - Fax:407-398-0117
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8767111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4605400OtherCIGNA
FL7954734OtherAETNA