Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TR0400X | Rehabilitation Psychologist |
NPI | 1073115747 |
---|---|
Provider Name | Jake Bartley Wilson |
First Address | Reno, NV 89509-4210 |
Second Address | Reno, NV 89502-1413 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/11/2020 |
Last Update Date | 09/11/2020 |