Healthcare Provider Details

I. General information

NPI: 1487528162
Provider Name (Legal Business Name): ELISHA JAEDON WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2025
Last Update Date: 10/24/2025
Certification Date: 10/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 N ROADRUNNER PKWY APT 1207
LAS CRUCES NM
88011-7088
US

IV. Provider business mailing address

1151 N ROADRUNNER PKWY APT 1207
LAS CRUCES NM
88011-7088
US

V. Phone/Fax

Practice location:
  • Phone: 909-234-5665
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: