Basic Information
| Provider Information | |||||||||
| NPI: | 1942551619 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1009 N CUMMINGS LN | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615719646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096702020 | ||||||||
| FaxNumber: | 3096939754 | ||||||||
| Practice Location | |||||||||
| Address1: | 1009 N CUMMINGS LN | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615719646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096702020 | ||||||||
| FaxNumber: | 3094447863 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2012 | ||||||||
| LastUpdateDate: | 08/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046010759 | IL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 046010759 | 01 | IL | STATE LICENSE | OTHER |