Provider Demographics
NPI:1417286410
Name:WILSON FAMILY CHIROPRACTIC
Entity type:Organization
Organization Name:WILSON FAMILY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:678-205-1573
Mailing Address - Street 1:2498 JETT FERRY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338-3062
Mailing Address - Country:US
Mailing Address - Phone:678-205-1573
Mailing Address - Fax:678-205-1574
Practice Address - Street 1:2498 JETT FERRY RD STE 100
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-3062
Practice Address - Country:US
Practice Address - Phone:678-205-1573
Practice Address - Fax:678-205-1574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-22
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008587111N00000X, 111NP0017X, 111NR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No111NP0017XChiropractic ProvidersChiropractorPediatric ChiropractorGroup - Single Specialty
No111NR0200XChiropractic ProvidersChiropractorRadiologyGroup - Single Specialty