Provider Demographics
NPI:1417787169
Name:WILSON, JEREMY MICHAEL
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:MICHAEL
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 1:1907 FITZGERALD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92583-6068
Mailing Address - Country:US
Mailing Address - Phone:410-279-1209
Mailing Address - Fax:
Practice Address - Street 1:33353 YUCAIPA BLVD
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-2018
Practice Address - Country:US
Practice Address - Phone:951-465-3664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program