Basic Information
| Provider Information | |||||||||
| NPI: | 1134306673 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CARE COORDINATOR | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 333 CHURCH STREET | ||||||||
| Address2: | P.O. BOX 1231 | ||||||||
| City: | WRANGELL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 999291231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9078742373 | ||||||||
| FaxNumber: | 9078742576 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | WRANGELL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9078742373 | ||||||||
| FaxNumber: | 9078742576 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2008 | ||||||||
| LastUpdateDate: | 01/28/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | CMG543 | AK | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.