Basic Information
| Provider Information | |||||||||
| NPI: | 1205094406 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JENNY | ||||||||
| MiddleName: | LUPOVICI | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 707 SW GAINES ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972392901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038046824 | ||||||||
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| Practice Location | |||||||||
| Address1: | 707 SW GAINES ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972392901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034949113 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2008 | ||||||||
| LastUpdateDate: | 05/21/2013 | ||||||||
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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 | 2084N0402X | MD162292 | OR | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology | 2084N0402X | MD441944 | PA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
No ID Information.