Provider Demographics
NPI:1154686657
Name:WILSON, JENNIFER MARIE (MD)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 S MONACO ST STE 210
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80237-3487
Mailing Address - Country:US
Mailing Address - Phone:303-788-8808
Mailing Address - Fax:303-788-6653
Practice Address - Street 1:4567 E 9TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80220-3941
Practice Address - Country:US
Practice Address - Phone:303-320-2455
Practice Address - Fax:303-320-7189
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301100484207V00000X
CODR.0056560207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO38792788Medicaid
CO525695YTU0Medicare PIN