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General NPI Number Information
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NPI Number | 1396307096
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Entity Type | Individual
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Provider Name | JASON ELIAS WILSON I
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Gender | Male
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Dates
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Enumeration Date | 07/02/2019
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Last Update Date | 07/02/2019
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Provider Practice Location Address
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Address Line | 217 S KING ST
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City | LEESBURG
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State | VA
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Zip | 20175-2905
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Country | US
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Telephone | 703-464-7400
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Fax | 703-464-0908
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Provider Business Mailing Address
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Address Line | 2917 26TH ST NE
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City | WASHINGTON
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State | DC
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Zip | 20018-2515
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Country | US
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Telephone | 202-664-3183
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State | DC
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