Individual
MR. JERRY WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
HWY 491 N. PINON ST., RED MODULAR BLDG, SHIPROCK, NM 87420-1830
(505) 368-1050
(505) 368-1055
Mailing address
PO BOX 1830, SHIPROCK, NM 87420-1830
(505) 368-1050
(505) 368-1055
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
0122591
NM
Other
Enumeration date
12/08/2009
Last updated
12/08/2009
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