Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | 3956 | OR |
Y | 111NS0005X | Chiropractic Sports Physician | 3956 | OR |
NPI | 1104059104 |
---|---|
Provider Name | Dr. Jared Wilson |
First Address | Springfield, OR 97477-1339 |
Second Address | Springfield, OR 97477-1339 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/08/2009 |
Last Update Date | 24/03/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
500707661 | (05) | OR |