Provider Demographics
NPI:1851624308
Name:WILDMAN, JASON M
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:M
Last Name:WILDMAN
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 1:207 W 106TH ST
Mailing Address - Street 2:7B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-3620
Mailing Address - Country:US
Mailing Address - Phone:917-715-6664
Mailing Address - Fax:212-792-6058
Practice Address - Street 1:50 W 23RD ST
Practice Address - Street 2:9TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-5205
Practice Address - Country:US
Practice Address - Phone:212-989-2990
Practice Address - Fax:212-792-6058
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-16
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0816741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical