Healthcare Provider Details

I. General information

NPI: 1922350321
Provider Name (Legal Business Name): JARED LANE WILSON DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2012
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8611 N DIVISION ST STE A
SPOKANE WA
99208-5946
US

IV. Provider business mailing address

3009 W DALTON AVE
SPOKANE WA
99205-2220
US

V. Phone/Fax

Practice location:
  • Phone: 509-599-2766
  • Fax:
Mailing address:
  • Phone: 509-599-2766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH60542353
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberCH60542353
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberCH60542353
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: