Provider Demographics
NPI:1912170333
Name:WILSON, JON LLOYD (LMSW)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:LLOYD
Last Name:WILSON
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 PARKLANE BLVD
Mailing Address - Street 2:STE 695
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2776
Mailing Address - Country:US
Mailing Address - Phone:313-271-8170
Mailing Address - Fax:313-271-8353
Practice Address - Street 1:18181 OAKWOOD BLVD
Practice Address - Street 2:OAKWOOD MEDICAL BUILDING SUITE 311
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-5032
Practice Address - Country:US
Practice Address - Phone:313-271-8170
Practice Address - Fax:313-271-8353
Is Sole Proprietor?:No
Enumeration Date:2008-04-07
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010790691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801079069OtherL.M.S.W.