Provider Demographics
NPI:1326314634
Name:WILSON, JILL BETHANY (FNP)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:BETHANY
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-3962
Mailing Address - Country:US
Mailing Address - Phone:618-453-3311
Mailing Address - Fax:
Practice Address - Street 1:374 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-3962
Practice Address - Country:US
Practice Address - Phone:618-453-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-30
Last Update Date:2025-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009467363L00000X
IL277003898363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370966854005Medicaid
ILCF3444OtherRR MEDICARE
IL370966854002Medicaid
IL209.009467OtherILLINOIS ADVANCE PRACTICE NURSE LICENSE
ILCF3444OtherRR MEDICARE
IL370966854005Medicaid