Basic Information
| Provider Information | |||||||||
| NPI: | 1154686657 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4900 S MONACO ST STE 210 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802373487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037888808 | ||||||||
| FaxNumber: | 3037886653 | ||||||||
| Practice Location | |||||||||
| Address1: | 4567 E 9TH AVE | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802203941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033202455 | ||||||||
| FaxNumber: | 3033207189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2012 | ||||||||
| LastUpdateDate: | 02/19/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 4301100484 | MI | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | DR.0056560 | CO | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 38792788 | 05 | CO | MEDICAID |