Basic Information
| Provider Information | |||||||||
| NPI: | 1811341522 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 155 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BREWSTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105091521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452796999 | ||||||||
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| Practice Location | |||||||||
| Address1: | 155 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BREWSTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105091521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452796999 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2016 | ||||||||
| LastUpdateDate: | 09/03/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 64627 | MN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 62647 | MN | N | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 300770 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.