Provider Demographics
NPI:1619393410
Name:WILLSON, JACKIE
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:WILLSON
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 1:4400 BAYOU BLVD STE 39B
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-1911
Mailing Address - Country:US
Mailing Address - Phone:850-478-9701
Mailing Address - Fax:850-478-9750
Practice Address - Street 1:4400 BAYOU BLVD STE 39B
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-1911
Practice Address - Country:US
Practice Address - Phone:850-478-9701
Practice Address - Fax:850-478-9750
Is Sole Proprietor?:No
Enumeration Date:2014-03-17
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL299994180163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse