Provider Demographics
NPI:1669241840
Name:WILSON, JACOB (DC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2540 NEW BUTLER RD STE 201
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:16101-3231
Mailing Address - Country:US
Mailing Address - Phone:724-856-8390
Mailing Address - Fax:724-856-8573
Practice Address - Street 1:2540 NEW BUTLER RD STE 201
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:PA
Practice Address - Zip Code:16101-3231
Practice Address - Country:US
Practice Address - Phone:724-856-8390
Practice Address - Fax:724-856-8573
Is Sole Proprietor?:No
Enumeration Date:2023-12-28
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC011893111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor