Provider Demographics
NPI:1902932783
Name:WILSON, JAMES CLINTON (PHD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:CLINTON
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:JAMES
Other - Middle Name:CLINTON
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:49 CREEKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-1076
Mailing Address - Country:US
Mailing Address - Phone:415-499-7767
Mailing Address - Fax:415-485-1939
Practice Address - Street 1:712 D ST STE N
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3706
Practice Address - Country:US
Practice Address - Phone:415-485-1939
Practice Address - Fax:415-485-1939
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10276103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist