Provider Demographics
NPI:1194822049
Name:JACQUELINE S. WILSON, M.D., P.C.
Entity Type:Organization
Organization Name:JACQUELINE S. WILSON, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:S
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-586-7515
Mailing Address - Street 1:321 E MAIN ST
Mailing Address - Street 2:SUITE 309
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-6241
Mailing Address - Country:US
Mailing Address - Phone:406-586-7515
Mailing Address - Fax:406-522-0481
Practice Address - Street 1:321 E MAIN ST
Practice Address - Street 2:SUITE 309
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6241
Practice Address - Country:US
Practice Address - Phone:406-586-7515
Practice Address - Fax:406-522-0481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT8315261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT93296OtherBCBS
MT0152425Medicaid
MTD27161Medicare UPIN