Provider Demographics
NPI:1487528162
Name:WILSON, ELISHA JAEDON
Entity type:Individual
Prefix:
First Name:ELISHA
Middle Name:JAEDON
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 1:1151 N ROADRUNNER PKWY APT 1207
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-7088
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1151 N ROADRUNNER PKWY APT 1207
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-7088
Practice Address - Country:US
Practice Address - Phone:909-234-5665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-03
Last Update Date:2025-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician