Provider Demographics
NPI:1013209162
Name:WILSON, KALENNA JEAN (DC)
Entity Type:Individual
Prefix:
First Name:KALENNA
Middle Name:JEAN
Last Name:WILSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MO
Mailing Address - Zip Code:65483-1621
Mailing Address - Country:US
Mailing Address - Phone:417-967-2470
Mailing Address - Fax:
Practice Address - Street 1:301 S 1ST ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MO
Practice Address - Zip Code:65483-1621
Practice Address - Country:US
Practice Address - Phone:417-967-2470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011011887111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor