Individual
DR. JEFFREY JOHN WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
2017 JEFFERSON ST SW, ROANOKE, VA 24014-2419
(540) 853-0900
(540) 853-0518
Mailing address
2017 JEFFERSON ST SW, ROANOKE, VA 24014-2419
(540) 853-0900
(540) 853-0518
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
0101-256187
VA
2084P0800X
Psychiatry Physician
8225057
UT
2084P0802X
Addiction Psychiatry Physician
0101-256187
VA
2084P0802X
Addiction Psychiatry Physician
8225057
UT
2084P0804X
Child & Adolescent Psychiatry Physician
Primary
0101-256187
VA
2084P0804X
Child & Adolescent Psychiatry Physician
8225057
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
VVD703A
MEDICARE PTAN
VA
Enumeration date
03/27/2007
Last updated
12/24/2014
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