Provider Demographics
NPI:1104059104
Name:WILSON, JARED (DC)
Entity type:Individual
Prefix:DR
First Name:JARED
Middle Name:
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 1:1150 E ELDORADO PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:LITTLE ELM
Mailing Address - State:TX
Mailing Address - Zip Code:75068-5504
Mailing Address - Country:US
Mailing Address - Phone:972-292-9863
Mailing Address - Fax:972-292-9861
Practice Address - Street 1:1150 E ELDORADO PKWY STE 300
Practice Address - Street 2:
Practice Address - City:LITTLE ELM
Practice Address - State:TX
Practice Address - Zip Code:75068-5504
Practice Address - Country:US
Practice Address - Phone:972-292-9863
Practice Address - Fax:972-292-9861
Is Sole Proprietor?:No
Enumeration Date:2009-08-25
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3956111N00000X, 111NS0005X
TX15157111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500707661Medicaid