Healthcare Provider Details

I. General information

NPI: 1992055461
Provider Name (Legal Business Name): JONATHAN DANIEL WILKS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2012
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 WOODROSE RD NW
ALBUQUERQUE NM
87114
US

IV. Provider business mailing address

4300 WOODROSE RD NW
ALBUQUERQUE NM
87114-5578
US

V. Phone/Fax

Practice location:
  • Phone: 505-553-6110
  • Fax:
Mailing address:
  • Phone: 505-553-6110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-2909
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: