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General NPI Number Information
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NPI Number | 1235651720
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Entity Type | Individual
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Provider Name | JORDAN WILSON PA-C
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Gender | Male
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Dates
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Enumeration Date | 07/17/2017
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Last Update Date | 03/12/2025
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Provider Practice Location Address
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Address Line | 100 NEW STATE HWY
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City | RAYNHAM
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State | MA
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Zip | 02767-5423
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Country | US
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Telephone | 781-666-2711
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Fax | 781-666-2712
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Provider Business Mailing Address
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Address Line | 100 NEW STATE HWY
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City | RAYNHAM
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State | MA
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Zip | 02767-5423
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Country | US
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Telephone | 781-666-2711
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Fax | 781-666-2712
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084B0040X
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Taxonomy Name | Behavioral Neurology & Neuropsychiatry Physician
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License Number | 9110440
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA60855409
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License Number State | WA
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA101388
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License Number State | MA
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