Provider Demographics
NPI:1972018760
Name:WILSON, JASON SCOTT
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:SCOTT
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:PO BOX 2272
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72602-2272
Mailing Address - Country:US
Mailing Address - Phone:479-899-2176
Mailing Address - Fax:
Practice Address - Street 1:1225 W HUDSON RD
Practice Address - Street 2:TELEHEALTH ONLY
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756
Practice Address - Country:US
Practice Address - Phone:479-899-2176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-03
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1703190101YM0800X
101YP2500X
ARP2112003101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health