Provider Demographics
NPI:1962955435
Name:WILSON, JEFFREY JOHN (AT/L)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JOHN
Last Name:WILSON
Suffix:
Gender:M
Credentials:AT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37480 SCOTSDALE CIR
Mailing Address - Street 2:#301
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-7553
Mailing Address - Country:US
Mailing Address - Phone:408-806-2583
Mailing Address - Fax:
Practice Address - Street 1:24062 TAFT RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-3022
Practice Address - Country:US
Practice Address - Phone:408-806-2583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-01
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5421992255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer