Provider Demographics
NPI:1992392187
Name:WILSON, JONATHAN RASHIED JR (EDD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:RASHIED
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6504 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19142-2817
Mailing Address - Country:US
Mailing Address - Phone:267-232-8383
Mailing Address - Fax:
Practice Address - Street 1:6504 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19142-2817
Practice Address - Country:US
Practice Address - Phone:267-232-8383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-22
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEQ3-0000199171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator