Provider Demographics
NPI:1093581423
Name:WILSON, JENNIFER KELLY (DNP, RN, CPNP-PC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KELLY
Last Name:WILSON
Suffix:
Gender:F
Credentials:DNP, RN, CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 BEACON ST APT 312
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-2223
Mailing Address - Country:US
Mailing Address - Phone:203-339-2161
Mailing Address - Fax:
Practice Address - Street 1:1600 BEACON ST APT 312
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-2223
Practice Address - Country:US
Practice Address - Phone:203-339-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-27
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2363283363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics