MEDICARE: MR. JAYME ROBERT WILSON MA,CCC-SLP

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	235Z00000X	Speech-Language Pathologist	12029617	MI

General Provider Information

NPI Number	:	1932416138
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAYME ROBERT WILSON MA,CCC-SLP

Provider Business Mailing Address
First Line	:	3285 MARTIN RD
Second Line	:	SUITE 104
City	:	COMMERCE TOWNSHIP
State	:	MI
Zip	:	48390-1601
Country	:	US
Telephone Number	:	248-669-1230
Fax Number	:	248-669-4745

Provider Business Practice Location Address
First Line	:	3285 MARTIN RD
Second Line	:	SUITE 104
City	:	COMMERCE TOWNSHIP
State	:	MI
Zip	:	48390-1601
Country	:	US
Telephone Number	:	248-669-1230
Fax Number	:	248-669-4745

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

Provider Enumeration Date	:	09/09/2010
Last Update Date	:	09/09/2010

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Directions to “ MR. JAYME ROBERT WILSON MA,CCC-SLP” Practice Location

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