Provider Demographics
NPI:1053663682
Name:WILSON, JENNIFER M
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
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:PO BOX 5595
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92662-5595
Mailing Address - Country:US
Mailing Address - Phone:951-214-8775
Mailing Address - Fax:
Practice Address - Street 1:4736 VICTORIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-5660
Practice Address - Country:US
Practice Address - Phone:951-214-8775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-05
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA212974164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse