Active NPI
Jerry Wilson
- Addiction (Substance Use Disorder) Counselor
- Shiprock, NM
National Provider Identifier
1962731786
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Addiction (Substance Use Disorder) Counselor
- License
- 0122591
- Practice address
- Hwy 491 N. Pinon St.
Red Modular BLDG
Shiprock, NM 87420-1830 - Phone
- (505) 368-1050
- Fax
- (505) 368-1055
- NPI assigned
- Dec 8, 2009
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Addiction (Substance Use Disorder) Counselor | 101YA0400X | 0122591 | NM | Primary |
Addresses
Primary practice location
Hwy 491 N. Pinon St.
Red Modular BLDG
Shiprock, NM 87420-1830
Mailing address
PO Box 1830
Shiprock, NM 87420-1830
Phone (505) 368-1050
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 0122591 | NM | MD | Addiction (Substance Use Disorder) Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1260230400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1260230400000",
"number": "1962731786",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 1830",
"city": "SHIPROCK",
"state": "NM",
"postal_code": "874201830",
"telephone_number": "505-368-1050",
"fax_number": "505-368-1055"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "HWY 491 N. PINON ST.",
"address_2": "RED MODULAR BLDG",
"city": "SHIPROCK",
"state": "NM",
"postal_code": "874201830",
"telephone_number": "505-368-1050",
"fax_number": "505-368-1055"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WILSON",
"first_name": "JERRY",
"name_prefix": "Mr.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2009-12-08",
"last_updated": "2009-12-08",
"status": "A"
},
"taxonomies": [
{
"code": "101YA0400X",
"taxonomy_group": "",
"desc": "Counselor, Addiction (Substance Use Disorder)",
"state": "NM",
"license": "0122591",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Shiprock, NM
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 8, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.