Provider Demographics
NPI:1932610045
Name:WILSON, JOSEPH R
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:R
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 1:2604 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-2645
Mailing Address - Country:US
Mailing Address - Phone:615-482-9209
Mailing Address - Fax:
Practice Address - Street 1:622 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-6211
Practice Address - Country:US
Practice Address - Phone:318-398-0945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-16
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator