Provider Demographics
NPI:1962731786
Name:WILSON, JERRY
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:
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:PO BOX 1830
Mailing Address - Street 2:
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420-1830
Mailing Address - Country:US
Mailing Address - Phone:505-368-1050
Mailing Address - Fax:505-368-1055
Practice Address - Street 1:HWY 491 N. PINON ST.
Practice Address - Street 2:RED MODULAR BLDG
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420-1830
Practice Address - Country:US
Practice Address - Phone:505-368-1050
Practice Address - Fax:505-368-1055
Is Sole Proprietor?:No
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0122591101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)