Provider Demographics
NPI:1255703641
Name:WILSON, JARRED DOUGLAS
Entity type:Individual
Prefix:MR
First Name:JARRED
Middle Name:DOUGLAS
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 N NORTHCAPE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-1930
Mailing Address - Country:US
Mailing Address - Phone:909-374-0902
Mailing Address - Fax:
Practice Address - Street 1:800 N NORTHCAPE AVE
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-1930
Practice Address - Country:US
Practice Address - Phone:909-374-0902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-23
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman