Provider Demographics
NPI:1801185814
Name:WILSON, JEFFREY MATTHEW (RN)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:MATTHEW
Last Name:WILSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7750 VIA FRANCESCO UNIT 2
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-5149
Mailing Address - Country:US
Mailing Address - Phone:562-682-5069
Mailing Address - Fax:
Practice Address - Street 1:7750 VIA FRANCESCO UNIT 2
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92129-5149
Practice Address - Country:US
Practice Address - Phone:562-682-5069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-30
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA742298163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse