MEDICARE: JEREMY WILSON

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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1962929216
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMY WILSON

Provider Business Mailing Address
First Line	:	10 SILVER VIEW CT
Second Line	:
City	:	MORGANTOWN
State	:	WV
Zip	:	26505-3932
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10 SILVER VIEW CT
Second Line	:
City	:	MORGANTOWN
State	:	WV
Zip	:	26505-3932
Country	:	US
Telephone Number	:	304-669-2719
Fax Number	:

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

Provider Enumeration Date	:	08/28/2017
Last Update Date	:	08/28/2017

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Directions to “ JEREMY WILSON ” Practice Location

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