Healthcare Provider Details

I. General information

NPI: 1730618356
Provider Name (Legal Business Name): JACOB DAMMON WILSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 01/07/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1935 ROUTE 70 E
CHERRY HILL NJ
08003-2117
US

IV. Provider business mailing address

42 E LAUREL RD STE 2600
STRATFORD NJ
08084-1354
US

V. Phone/Fax

Practice location:
  • Phone: 856-428-7700
  • Fax: 856-325-4196
Mailing address:
  • Phone: 856-566-6875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number25MB12205900
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: