Provider Demographics
NPI:1154187995
Name:WILSON, JACOB AUTRY (RBT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:AUTRY
Last Name:WILSON
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38413 DEERWOODS DR
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32736-9492
Mailing Address - Country:US
Mailing Address - Phone:352-617-4616
Mailing Address - Fax:
Practice Address - Street 1:437 W ARDICE AVE
Practice Address - Street 2:SUITE 481
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-3408
Practice Address - Country:US
Practice Address - Phone:407-530-5063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-27
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB1068402106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty