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General NPI Number Information
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NPI Number | 1841546900
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Entity Type | Individual
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Provider Name | JOHN JAY WILSON C.O.T.A./L.
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Gender | Male
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Dates
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Enumeration Date | 07/26/2012
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Last Update Date | 07/26/2012
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Provider Practice Location Address
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Address Line | 2222 WELBORN ST
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City | DALLAS
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State | TX
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Zip | 75219-3924
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Country | US
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Telephone | 214-559-7786
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Fax |
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Provider Business Mailing Address
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Address Line | 2650 SUNSET DR
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City | GLENN HEIGHTS
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State | TX
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Zip | 75154-2022
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Country | US
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Telephone | 214-808-3545
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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 | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | 208194
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License Number State | TX
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