Basic Information
| Provider Information | |||||||||
| NPI: | 1013338870 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JASON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3404 SAN JUAN TRL | ||||||||
| Address2: | |||||||||
| City: | MOORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731602165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107025792 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2220 N CLASSEN BLVD | ||||||||
| Address2: | STE E | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731065809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055281748 | ||||||||
| FaxNumber: | 4055281802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2013 | ||||||||
| LastUpdateDate: | 12/21/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.