Healthcare Provider Details

I. General information

NPI: 1235651720
Provider Name (Legal Business Name): JORDAN WILSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2017
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NEW STATE HWY
RAYNHAM MA
02767-5423
US

IV. Provider business mailing address

100 NEW STATE HWY
RAYNHAM MA
02767-5423
US

V. Phone/Fax

Practice location:
  • Phone: 781-666-2711
  • Fax: 781-666-2712
Mailing address:
  • Phone: 781-666-2711
  • Fax: 781-666-2712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number9110440
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60855409
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA101388
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: