Provider Demographics
NPI:1134688831
Name:WILCOX, JAMIE (LAC)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:WILCOX
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14033 GADWALL LN
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:MN
Mailing Address - Zip Code:55374-8770
Mailing Address - Country:US
Mailing Address - Phone:715-497-4292
Mailing Address - Fax:
Practice Address - Street 1:12455 RIDGEDALE DR
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1786
Practice Address - Country:US
Practice Address - Phone:952-314-7035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-13
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1905171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist