Provider Demographics
NPI:1255876538
Name:WILSON, JESSE
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
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 1:1545 HOTEL CIR S
Mailing Address - Street 2:STE 300
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3412
Mailing Address - Country:US
Mailing Address - Phone:619-550-3959
Mailing Address - Fax:
Practice Address - Street 1:1545 HOTEL CIR S
Practice Address - Street 2:STE 300
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3412
Practice Address - Country:US
Practice Address - Phone:619-550-3959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-22
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)