Provider Demographics
NPI:1225244692
Name:WILSON, JACQUELINE GOLDEN (OTR)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:GOLDEN
Last Name:WILSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15115 EASTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:UPPERCO
Mailing Address - State:MD
Mailing Address - Zip Code:21155-9746
Mailing Address - Country:US
Mailing Address - Phone:410-429-1906
Mailing Address - Fax:410-429-1906
Practice Address - Street 1:15115 EASTVIEW DR
Practice Address - Street 2:
Practice Address - City:UPPERCO
Practice Address - State:MD
Practice Address - Zip Code:21155-9746
Practice Address - Country:US
Practice Address - Phone:410-429-1906
Practice Address - Fax:410-429-1906
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01516225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDJ242Medicare UPIN
MDH888-0001Medicare UPIN