Basic Information
| Provider Information | |||||||||
| NPI: | 1073924742 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 380 SUMMIT AVENUE | ||||||||
| Address2: | MSO PHYSICIAN BILLING | ||||||||
| City: | STEUBENVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 439522667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402837597 | ||||||||
| FaxNumber: | 7402837807 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | SAINT CLAIRSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 439507713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406952090 | ||||||||
| FaxNumber: | 7406954116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2014 | ||||||||
| LastUpdateDate: | 01/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34012758 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0219742 | 05 | OH | MEDICAID |