Provider Demographics
NPI:1861406431
Name:WILSON, JENNIFER L (PAC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2300 53RD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-7565
Mailing Address - Country:US
Mailing Address - Phone:563-322-0971
Mailing Address - Fax:563-324-0615
Practice Address - Street 1:520 VALLEY VIEW DR
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6152
Practice Address - Country:US
Practice Address - Phone:309-762-3621
Practice Address - Fax:309-762-3690
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL85002115363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
K26555Medicare ID - Type Unspecified
Q04055Medicare UPIN