Provider Demographics
NPI:1356349559
Name:WILSON, JACK KENNEY JR (MD)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:KENNEY
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:637 S KERR AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-8423
Mailing Address - Country:US
Mailing Address - Phone:910-799-1810
Mailing Address - Fax:910-452-2571
Practice Address - Street 1:637 S KERR AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-8423
Practice Address - Country:US
Practice Address - Phone:910-799-1810
Practice Address - Fax:910-452-2571
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC16755207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC02701OtherBCBS NC
NC8902701Medicaid
NC8902701Medicaid
NC02701OtherBCBS NC