Healthcare Provider Details

I. General information

NPI: 1720709736
Provider Name (Legal Business Name): JARED BENJAMIN WILSON DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2022
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2508 W NOB HILL BLVD
YAKIMA WA
98902-5104
US

IV. Provider business mailing address

PO BOX 8357
YAKIMA WA
98908-0357
US

V. Phone/Fax

Practice location:
  • Phone: 509-248-5555
  • Fax: 509-469-4938
Mailing address:
  • Phone: 509-966-5555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH.61340613
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: