MEDICARE: DR. JONATHAN B WILSON PHD, LMFT-S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	LMFT10000178	MA
2	106H00000X	Marriage & Family Therapist	203636	TX

General Provider Information

NPI Number	:	1679840227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN B WILSON PHD, LMFT-S

Provider Business Mailing Address
First Line	:	5130 GOODWIN AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75206-6205
Country	:	US
Telephone Number	:	972-638-7485
Fax Number	:

Provider Business Practice Location Address
First Line	:	5130 GOODWIN AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75206-6205
Country	:	US
Telephone Number	:	972-638-7485
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/28/2011
Last Update Date	:	08/05/2024

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