Provider Demographics
NPI:1902876667
Name:WILSON, JARED K (MD)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:K
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 LIBERTY SQ
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:KY
Mailing Address - Zip Code:42539-3392
Mailing Address - Country:US
Mailing Address - Phone:606-787-5044
Mailing Address - Fax:606-787-5029
Practice Address - Street 1:112 LIBERTY SQ
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:KY
Practice Address - Zip Code:42539-3392
Practice Address - Country:US
Practice Address - Phone:606-787-5044
Practice Address - Fax:606-787-5029
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY32177207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64321771Medicaid
KY64321771Medicaid