Provider Demographics
NPI:1104579531
Name:WILSON, JEFFREY TODD
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:TODD
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7943 HARGIS ST NW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-9645
Mailing Address - Country:US
Mailing Address - Phone:360-480-1410
Mailing Address - Fax:
Practice Address - Street 1:7943 HARGIS ST NW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-9645
Practice Address - Country:US
Practice Address - Phone:360-480-1410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-26
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00002628246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist