Provider Demographics
NPI:1104995604
Name:WILSON, JAY DAVID (DPT)
Entity type:Individual
Prefix:MR
First Name:JAY
Middle Name:DAVID
Last Name:WILSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:827 32ND AVE N
Mailing Address - Street 2:#108
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-1087
Mailing Address - Country:US
Mailing Address - Phone:701-271-1000
Mailing Address - Fax:701-526-3818
Practice Address - Street 1:3101 BROADWAY N
Practice Address - Street 2:SUITE C
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-1485
Practice Address - Country:US
Practice Address - Phone:701-271-1000
Practice Address - Fax:701-526-3818
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ND938225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist