Provider Demographics
NPI:1023668019
Name:WILSON, JONATHAN (MAED, ATC, LAT, CSCS)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:MAED, ATC, LAT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 UNION UNIVERSITY DR # 1811
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-3656
Mailing Address - Country:US
Mailing Address - Phone:731-661-5307
Mailing Address - Fax:
Practice Address - Street 1:1050 UNION UNIVERSITY DR # 1811
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3656
Practice Address - Country:US
Practice Address - Phone:731-661-5307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19992255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer