Provider Demographics
NPI:1679840227
Name:WILSON, JONATHAN B (PHD, LMFT-S)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:B
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHD, LMFT-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5130 GOODWIN AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-6205
Mailing Address - Country:US
Mailing Address - Phone:972-638-7485
Mailing Address - Fax:
Practice Address - Street 1:5130 GOODWIN AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206-6205
Practice Address - Country:US
Practice Address - Phone:972-638-7485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-28
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALMFT10000178106H00000X
TX203636106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist