Provider Demographics
NPI:1043644198
Name:WILSON, JENNIFER LEIGH (NP-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEIGH
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2358 LIFESTYLE WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-4907
Mailing Address - Country:US
Mailing Address - Phone:423-602-2750
Mailing Address - Fax:423-602-2762
Practice Address - Street 1:2358 LIFESTYLE WAY STE 100
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-4907
Practice Address - Country:US
Practice Address - Phone:423-602-2750
Practice Address - Fax:423-602-2762
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-26
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN17797363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5199886OtherBCBS
P01276010OtherRR MEDICARE
GA003140219AMedicaid
TNQ002644Medicaid
1035020I69Medicare PIN