Basic Information
| Provider Information | |||||||||
| NPI: | 1477588432 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 21418 | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895151418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757463202 | ||||||||
| FaxNumber: | 7757703588 | ||||||||
| Practice Location | |||||||||
| Address1: | 235 W 6TH ST | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895034548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757703188 | ||||||||
| FaxNumber: | 7757703588 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 01/23/2013 | ||||||||
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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 | 207P00000X | 10019 | NV | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 002016938 | 05 | NV | MEDICAID |