Provider Demographics
NPI:1972112217
Name:WILSON, JAMAL
Entity Type:Individual
Prefix:
First Name:JAMAL
Middle Name:
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 1:5408 HARBOURWATCH WAY APT 303
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-8392
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5408 HARBOURWATCH WAY APT 303
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-8392
Practice Address - Country:US
Practice Address - Phone:248-755-5301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-22
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.024863225700000X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist