Basic Information
| Provider Information | |||||||||
| NPI: | 1912170333 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | LLOYD | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | L.M.S.W. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 PARKLANE BLVD | ||||||||
| Address2: | STE 695 | ||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481262776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132718170 | ||||||||
| FaxNumber: | 3132718353 | ||||||||
| Practice Location | |||||||||
| Address1: | 18181 OAKWOOD BLVD | ||||||||
| Address2: | OAKWOOD MEDICAL BUILDING SUITE 311 | ||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481245032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132718170 | ||||||||
| FaxNumber: | 3132718353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2008 | ||||||||
| LastUpdateDate: | 09/15/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801079069 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6801079069 | 01 | MI | L.M.S.W. | OTHER |