Provider Demographics
NPI:1023318276
Name:WILSON, JACOB R (BA)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:R
Last Name:WILSON
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8616 NORTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5309
Mailing Address - Country:US
Mailing Address - Phone:815-391-1000
Mailing Address - Fax:
Practice Address - Street 1:8616 NORTHERN AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5309
Practice Address - Country:US
Practice Address - Phone:815-391-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-21
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health