Provider Demographics
NPI:1730345612
Name:WILSON, JOHN WESLEY JR (PSYD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WESLEY
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 ANNWICKS DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-5407
Mailing Address - Country:US
Mailing Address - Phone:404-246-1257
Mailing Address - Fax:
Practice Address - Street 1:3115 ROSWELL RD
Practice Address - Street 2:SUITE 201
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-7605
Practice Address - Country:US
Practice Address - Phone:404-246-1257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-31
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003201103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical