Provider Demographics
NPI:1184164287
Name:JEFFREY, WILSON (OTR/L)
Entity type:Individual
Prefix:MR
First Name:WILSON
Middle Name:
Last Name:JEFFREY
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:658 PAULA DRIVE
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40977
Mailing Address - Country:US
Mailing Address - Phone:606-306-5174
Mailing Address - Fax:
Practice Address - Street 1:ADDRESS: 235 NEW WILSON LANE
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965
Practice Address - Country:US
Practice Address - Phone:606-248-0925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-08
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY172346225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist