Provider Demographics
NPI:1457678377
Name:WILSON, JACQUELINE DEANNA (MD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:DEANNA
Last Name:WILSON
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 N 39TH ST
Mailing Address - Street 2:PPMC - MUTCH 7
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-5548
Mailing Address - Country:US
Mailing Address - Phone:215-662-8777
Mailing Address - Fax:215-243-4601
Practice Address - Street 1:3737 MARKET STREET
Practice Address - Street 2:9TH FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-5548
Practice Address - Country:US
Practice Address - Phone:215-662-8777
Practice Address - Fax:215-243-4601
Is Sole Proprietor?:No
Enumeration Date:2010-05-02
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD461194208000000X, 2080A0000X, 2083A0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine