Provider Demographics
NPI:1003164971
Name:WILCOX, JESSICA LYNN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:WILCOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4295 JEFFERSON DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:BEECH ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29842-4824
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4295 JEFFERSON DAVIS HWY
Practice Address - Street 2:
Practice Address - City:BEECH ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29842-4824
Practice Address - Country:US
Practice Address - Phone:803-593-5196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-26
Last Update Date:2012-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13418183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist