Provider Demographics
NPI:1962029165
Name:WILSON, JACOB ALLEN (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ALLEN
Last Name:WILSON
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5030 BOARDWALK DR STE 150
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-3160
Mailing Address - Country:US
Mailing Address - Phone:719-726-1077
Mailing Address - Fax:719-960-3101
Practice Address - Street 1:5030 BOARDWALK DR STE 150
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-3160
Practice Address - Country:US
Practice Address - Phone:719-726-1077
Practice Address - Fax:719-960-3101
Is Sole Proprietor?:No
Enumeration Date:2020-07-03
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0996156-NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000191072Medicaid