Individual
JARED KENT WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C, MPAS, MED, ATC
Contact information
Practice address
777 HOSPITAL WAY, SOUTH MOB, SUITE 204, POCATELLO, ID 83201-5175
(208) 239-2110
(208) 239-2119
Mailing address
777 HOSPITAL WAY, SOUTH MOB, SUITE 204, POCATELLO, ID 83201-5175
(208) 239-2110
(208) 239-2119
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
AT-492
ID
363AS0400X
Surgical Physician Assistant
Primary
PA-952
ID
Other
Enumeration date
05/14/2007
Last updated
08/03/2025
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