Provider Demographics
NPI:1922350321
Name:WILSON, JARED LANE (DC)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:LANE
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 1:3009 W DALTON AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-2220
Mailing Address - Country:US
Mailing Address - Phone:509-599-2766
Mailing Address - Fax:
Practice Address - Street 1:8611 N DIVISION ST STE A
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-5946
Practice Address - Country:US
Practice Address - Phone:509-599-2766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-09
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH60542353111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor