Provider Demographics
NPI:1083950976
Name:WILSON, JESSICA LYNN (MSN FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:MSN FNP-BC
Other - Prefix:MRS
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:SPENCER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:436 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HALE
Mailing Address - State:MI
Mailing Address - Zip Code:48739-9246
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:436 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HALE
Practice Address - State:MI
Practice Address - Zip Code:48739-9246
Practice Address - Country:US
Practice Address - Phone:989-892-7722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-20
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704227052363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1083950976Medicaid
MIMI1172008Medicare UPIN