Healthcare Provider Details

I. General information

NPI: 1235132531
Provider Name (Legal Business Name): JASON B WILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 04/22/2022
Certification Date: 04/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 GRAMMONT ST STE 300
MONROE LA
71201-7403
US

IV. Provider business mailing address

312 GRAMMONT ST STE 300
MONROE LA
71201-7403
US

V. Phone/Fax

Practice location:
  • Phone: 318-388-4030
  • Fax: 318-325-8437
Mailing address:
  • Phone: 318-388-4030
  • Fax: 318-324-3334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number13062R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: