Healthcare Provider Details

I. General information

NPI: 1912170333
Provider Name (Legal Business Name): JON LLOYD WILSON L.M.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2008
Last Update Date: 09/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18181 OAKWOOD BLVD OAKWOOD MEDICAL BUILDING SUITE 311
DEARBORN MI
48124-5032
US

IV. Provider business mailing address

6 PARKLANE BLVD STE 695
DEARBORN MI
48126-2776
US

V. Phone/Fax

Practice location:
  • Phone: 313-271-8170
  • Fax: 313-271-8353
Mailing address:
  • Phone: 313-271-8170
  • Fax: 313-271-8353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801079069
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: