Basic Information
| Provider Information | |||||||||
| NPI: | 1326047911 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JENSEN | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 955 W SOUTHERN AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852104903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809611865 | ||||||||
| FaxNumber: | 4808938172 | ||||||||
| Practice Location | |||||||||
| Address1: | 440 N HIGHWAY 90 BYP STE B3 | ||||||||
| Address2: | |||||||||
| City: | SIERRA VISTA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856352295 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204597466 | ||||||||
| FaxNumber: | 5204580533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2005 | ||||||||
| LastUpdateDate: | 11/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2656 | OK | N | Eye and Vision Services Providers | Optometrist | 152W00000X | OPT-002406 | AZ | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.