Healthcare Provider Details

I. General information

NPI: 1962731786
Provider Name (Legal Business Name): MR. JERRY WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2009
Last Update Date: 12/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HWY 491 N. PINON ST. RED MODULAR BLDG
SHIPROCK NM
87420-1830
US

IV. Provider business mailing address

PO BOX 1830
SHIPROCK NM
87420-1830
US

V. Phone/Fax

Practice location:
  • Phone: 505-368-1050
  • Fax: 505-368-1055
Mailing address:
  • Phone: 505-368-1050
  • Fax: 505-368-1055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0122591
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: