Basic Information
| Provider Information | |||||||||
| NPI: | 1437351731 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 W WHITE RIVER BLVD | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473034988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8776685621 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2401 W UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473033428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7657473241 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2007 | ||||||||
| LastUpdateDate: | 03/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01063111A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | 01063111A | IN | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000564472 | 01 | IN | ANTHEM BC/BS | OTHER | P01403061 | 01 | IN | RAILROAD MEDICARE | OTHER | 000000711665 | 01 | IN | ANTHEM BC/BS | OTHER | P00775321 | 01 | IN | RAILROAD MEDICARE | OTHER | 200880830A | 05 | IN | MEDICAID | P00841097 | 01 | IN | RAILROAD MEDICARE | OTHER | P01087706 | 01 | IN | RAILROAD MEDICARE | OTHER |