Basic Information
| Provider Information | |||||||||
| NPI: | 1558378984 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1141 PEAR TREE LN STE 100 | ||||||||
| Address2: | |||||||||
| City: | NAPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945586485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072541770 | ||||||||
| FaxNumber: | 7072541779 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 HARTLE CT | ||||||||
| Address2: | |||||||||
| City: | NAPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945594078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072541775 | ||||||||
| FaxNumber: | 7072511779 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 02/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A86620 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A691360 | 01 | CA | PPIN | OTHER |