Provider Demographics
NPI:1588460836
Name:WILSON, JERROD
Entity type:Individual
Prefix:MR
First Name:JERROD
Middle Name:
Last Name:WILSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3702 N WINSTON AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74115-1208
Mailing Address - Country:US
Mailing Address - Phone:918-361-3740
Mailing Address - Fax:
Practice Address - Street 1:3702 N WINSTON AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74115-1208
Practice Address - Country:US
Practice Address - Phone:918-361-3740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-19
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist