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General NPI Number Information
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NPI Number | 1962029165
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Entity Type | Individual
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Provider Name | JACOB ALLEN WILSON PMHNP-BC
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Gender | Male
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Dates
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Enumeration Date | 07/03/2020
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Last Update Date | 04/03/2024
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Provider Practice Location Address
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Address Line | 5030 BOARDWALK DR STE 150
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City | COLORADO SPRINGS
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State | CO
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Zip | 80919-3160
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Country | US
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Telephone | 719-726-1077
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Fax | 719-960-3101
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Provider Business Mailing Address
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Address Line | 5030 BOARDWALK DR STE 150
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City | COLORADO SPRINGS
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State | CO
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Zip | 80919-3160
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Country | US
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Telephone | 719-726-1077
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Fax | 719-960-3101
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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 | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | APN.0996156-NP
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License Number State | CO
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