Provider Demographics
NPI:1245277979
Name:WILSON, JEFFREY GRANT (PHD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:GRANT
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27725 SANTA MARGARITA PKWY
Mailing Address - Street 2:SUITE 215
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6704
Mailing Address - Country:US
Mailing Address - Phone:949-272-3870
Mailing Address - Fax:929-951-2802
Practice Address - Street 1:27725 SANTA MARGARITA PKWY
Practice Address - Street 2:SUITE 215
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6704
Practice Address - Country:US
Practice Address - Phone:949-272-3870
Practice Address - Fax:949-951-2802
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2009-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12832103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19141AOtherMEDICARE GROUP ID
CAW19141AOtherMEDICARE GROUP ID
CAWCP12832BMedicare ID - Type Unspecified