Provider Demographics
NPI:1154933364
Name:WILSON, JEREMY GORDON
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:GORDON
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 1:10532 HADDINGTON DR NW
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-6956
Mailing Address - Country:US
Mailing Address - Phone:954-850-1125
Mailing Address - Fax:
Practice Address - Street 1:900 BRANCHVIEW DR NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2213
Practice Address - Country:US
Practice Address - Phone:704-780-4271
Practice Address - Fax:704-788-2016
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician