Provider Demographics
NPI:1801106158
Name:WILSON, JEREMY R (DC)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:R
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 1:3223A N PLEASANTBURG DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29609-2900
Mailing Address - Country:US
Mailing Address - Phone:864-558-8174
Mailing Address - Fax:864-558-8176
Practice Address - Street 1:3223A N PLEASANTBURG DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29609-2900
Practice Address - Country:US
Practice Address - Phone:864-558-8174
Practice Address - Fax:864-558-8176
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-19
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3590111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor