Healthcare Provider Details

I. General information

NPI: 1801185814
Provider Name (Legal Business Name): JEFFREY MATTHEW WILSON NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2011
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 HUTTON CENTRE DR STE 950
SANTA ANA CA
92707-8714
US

IV. Provider business mailing address

7750 VIA FRANCESCO UNIT 2
SAN DIEGO CA
92129-5149
US

V. Phone/Fax

Practice location:
  • Phone: 855-434-7763
  • Fax:
Mailing address:
  • Phone: 562-682-5069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95033035
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95033035
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: