Provider Demographics
NPI:1538919626
Name:WILSON, JENNIFER LEIGH (PCA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEIGH
Last Name:WILSON
Suffix:
Gender:F
Credentials:PCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 PEARL BATES AVE APT 30
Mailing Address - Street 2:
Mailing Address - City:EASTMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31023-5576
Mailing Address - Country:US
Mailing Address - Phone:478-230-5477
Mailing Address - Fax:
Practice Address - Street 1:611 PEARL BATES AVE APT 30
Practice Address - Street 2:
Practice Address - City:EASTMAN
Practice Address - State:GA
Practice Address - Zip Code:31023-5576
Practice Address - Country:US
Practice Address - Phone:478-230-5477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant