Provider Demographics
NPI:1861830036
Name:WILSON, JASON D
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:D
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 1:1740 N TACOMA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74127-2537
Mailing Address - Country:US
Mailing Address - Phone:918-693-8396
Mailing Address - Fax:918-583-6454
Practice Address - Street 1:1740 N TACOMA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-2537
Practice Address - Country:US
Practice Address - Phone:918-693-8396
Practice Address - Fax:918-583-6454
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-11
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst