Provider Demographics
NPI:1841009503
Name:WILSON, JUAN
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13815 SW PACIFIC HWY STE 50
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-4802
Mailing Address - Country:US
Mailing Address - Phone:503-899-9699
Mailing Address - Fax:
Practice Address - Street 1:13815 SW PACIFIC HWY STE 50
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-4802
Practice Address - Country:US
Practice Address - Phone:503-899-9699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-06
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21743225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist