Provider Demographics
NPI:1073111225
Name:WILSON, JILLIAN M (LAT, ATC)
Entity Type:Individual
Prefix:MS
First Name:JILLIAN
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7467 RIDGE RD STE 140
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:MD
Mailing Address - Zip Code:21076-3118
Mailing Address - Country:US
Mailing Address - Phone:410-768-5050
Mailing Address - Fax:
Practice Address - Street 1:1600 CRAIN HWY S STE 401
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-6413
Practice Address - Country:US
Practice Address - Phone:410-768-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-10
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program