Provider Demographics
NPI:1740038421
Name:WILSON, JONATHAN ROBERT
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ROBERT
Last Name:WILSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 WAGNER CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TALENT
Mailing Address - State:OR
Mailing Address - Zip Code:97540-6727
Mailing Address - Country:US
Mailing Address - Phone:559-908-0854
Mailing Address - Fax:
Practice Address - Street 1:140 S HOLLY ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-3113
Practice Address - Country:US
Practice Address - Phone:541-774-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-08
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR10085101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health