Basic Information
| Provider Information | |||||||||
| NPI: | 1811440092 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JACKILYN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 SUGAR CAMP CIR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | OAKWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454091981 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372768320 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3120 GOVERNORS PLACE BLVD | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454091328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372931622 | ||||||||
| FaxNumber: | 9372456308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2016 | ||||||||
| LastUpdateDate: | 11/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 019508 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2100X | RN328660 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.