Provider Demographics
NPI:1205939014
Name:WILSON, JEFFERY JAMES (DC)
Entity type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:JAMES
Last Name:WILSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1128 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-2523
Mailing Address - Country:US
Mailing Address - Phone:309-343-0028
Mailing Address - Fax:309-343-0191
Practice Address - Street 1:1128 MONROE ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-2523
Practice Address - Country:US
Practice Address - Phone:309-343-0028
Practice Address - Fax:309-343-0191
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009330111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
P0005879SOtherRR MEDICARE PALMETTO
04832006OtherBCBS
04832006OtherBCBS
U95956Medicare UPIN