Provider Demographics
NPI:1548371339
Name:WILSON, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:BOX 42
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-488-8672
Mailing Address - Fax:269-488-8673
Practice Address - Street 1:4613 W MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-2645
Practice Address - Country:US
Practice Address - Phone:269-488-8672
Practice Address - Fax:269-488-8673
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004667363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1153911890OtherBLUE CROSS BLUE SHIELD
MI0C97625131Medicare PIN