Healthcare Provider Details

I. General information

NPI: 1811015092
Provider Name (Legal Business Name): JEFFREY JOHN WILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 12/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2017 JEFFERSON ST SW
ROANOKE VA
24014-2419
US

IV. Provider business mailing address

2017 JEFFERSON ST SW
ROANOKE VA
24014-2419
US

V. Phone/Fax

Practice location:
  • Phone: 540-853-0900
  • Fax: 540-853-0518
Mailing address:
  • Phone: 540-853-0900
  • Fax: 540-853-0518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number8225057
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number8225057
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number8225057
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101-256187
License Number StateVA
# 5
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number0101-256187
License Number StateVA
# 6
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number0101-256187
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: