Provider Demographics
NPI:1730418476
Name:WILSON, JACOB WESLEY (DC)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:WESLEY
Last Name:WILSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2494 JETT FERRY RD
Mailing Address - Street 2:SUITE #103
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338-3090
Mailing Address - Country:US
Mailing Address - Phone:404-805-5961
Mailing Address - Fax:
Practice Address - Street 1:2494 JETT FERRY RD
Practice Address - Street 2:SUITE #103
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-3090
Practice Address - Country:US
Practice Address - Phone:404-805-5961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-09
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008587111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor