Provider Demographics
NPI:1669218137
Name:WILSON, JEREMIAH B (MSW)
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:B
Last Name:WILSON
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1874 AMIS AVE
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-1652
Mailing Address - Country:US
Mailing Address - Phone:520-955-3124
Mailing Address - Fax:
Practice Address - Street 1:1990 E LOHMAN AVE STE 217
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-3172
Practice Address - Country:US
Practice Address - Phone:520-955-3124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSWB-2024-04791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical