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General NPI Number Information
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NPI Number | 1376448415
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Entity Type | Individual
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Provider Name | JALEN RYAN WILSON BA
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Gender | Male
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Dates
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Enumeration Date | 10/09/2026
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Last Update Date | 10/09/2026
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Provider Practice Location Address
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Address Line | 2615 NAKOTA RD
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City | ROYAL OAK
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State | MI
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Zip | 48073-1816
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Country | US
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Telephone | 313-433-1003
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Fax |
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Provider Business Mailing Address
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Address Line | 22114 INKSTER RD
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City | SOUTHFIELD
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State | MI
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Zip | 48033-5029
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Country | US
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Telephone | 313-433-1003
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Fax |
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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 | 224Y00000X
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Taxonomy Name | Clinical Exercise Physiologist
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License Number |
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License Number State | NULL
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