Provider Demographics
NPI:1235651720
Name:WILSON, JORDAN (PA-C)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:WILSON
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 NEW STATE HWY
Mailing Address - Street 2:
Mailing Address - City:RAYNHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02767-5423
Mailing Address - Country:US
Mailing Address - Phone:781-666-2711
Mailing Address - Fax:781-666-2712
Practice Address - Street 1:100 NEW STATE HWY
Practice Address - Street 2:
Practice Address - City:RAYNHAM
Practice Address - State:MA
Practice Address - Zip Code:02767-5423
Practice Address - Country:US
Practice Address - Phone:781-666-2711
Practice Address - Fax:781-666-2712
Is Sole Proprietor?:No
Enumeration Date:2017-07-17
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL91104402084B0040X
WAPA60855409363A00000X
MAPA101388363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & Neuropsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2101119Medicaid