Healthcare Provider Details

I. General information

NPI: 1396930343
Provider Name (Legal Business Name): JAIME A B WILSON PH.D., ABPP, MSCP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JAIME ALEXANDER BAXTER WILSON PH.D., ABPP, MSCP

II. Dates (important events)

Enumeration Date: 09/12/2007
Last Update Date: 02/09/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1117 A ST
TACOMA WA
98402-5003
US

IV. Provider business mailing address

1117 A ST
TACOMA WA
98402-5003
US

V. Phone/Fax

Practice location:
  • Phone: 360-339-7752
  • Fax:
Mailing address:
  • Phone: 360-339-7752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSYC.PY.60074792
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: