Provider Demographics
NPI:1396930343
Name:WILSON, JAIME A B (PHD, ABPP, MSCP)
Entity type:Individual
Prefix:DR
First Name:JAIME
Middle Name:A B
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHD, ABPP, MSCP
Other - Prefix:DR
Other - First Name:JAIME
Other - Middle Name:ALEXANDER BAXTER
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD, ABPP, MSCP
Mailing Address - Street 1:1117 A ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-5003
Mailing Address - Country:US
Mailing Address - Phone:360-339-7752
Mailing Address - Fax:
Practice Address - Street 1:1117 A ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-5003
Practice Address - Country:US
Practice Address - Phone:360-339-7752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103G00000X
WAPSYC.PY.60074792103TC0700X
ID103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical