Provider Demographics
NPI:1043321748
Name:WILSON, JENNIFER L
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:WILSON
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 1:1221 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2701
Mailing Address - Country:US
Mailing Address - Phone:859-258-6200
Mailing Address - Fax:859-258-6203
Practice Address - Street 1:3050 HARRODSBURG RD
Practice Address - Street 2:STE 100
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-2747
Practice Address - Country:US
Practice Address - Phone:859-277-6102
Practice Address - Fax:859-977-0237
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41107208000000X, 2080A0000X
GA052858208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100028860Medicaid
SCG52858Medicaid
GA135542874AMedicaid
I12464Medicare UPIN